B I O E T H I C S Handout

Yerevan State Medical University Ministry of Science and Education of Republic of Armenia

S.H. Davtyan

YEREVAN – 2013

UDC 614.253(07)

The handout was guaranteed for publication by the academic council of the YSMU after M. Heratsi Editor of series: M.A. Harutyunyan PhD, Head of Chair of Philosophy of NAS of RA

Official Opponents: Holder of UNESCO Chair in Bioethics, president of World Associasion of Medical Law, professor Amnon Carmi (Israel) MD, professor, founding president of Forum of Ethical Committees of CIS Countries O. I. Kubar (Saints-Petersburg) MD, Professor, Chief Editor of “Armenian Medical Journal of Abstracts”.R. A. Hovhannisyan (Yerevan) V. D. Darbinyan (Yerevan) PhD B. G. Yudin (Moscow) PhD, Academician of NAS of RF.

Davtyan S.H. Bioethics, Handout, Yerevan/ Yerevan State Medical University/ 2013, 189 p. This handout is outstanding for it includes documents, declarations and resolutions on Bioethics adopted both by international organizations and the NA of RA. The handout presents thoughts and ideas of Medie- val Armenian thinkers. The theoretical topics are enriched by results of sociological surveys. Issues of applied ethics as well as analyses of specific case-studies collected from the medical practice of different foreign countries are also discussed in the handout. The book is designed for students, for PhD students and researchers as well as general public who are interested in Bioethics.

The electronic version of this text is created by: A. Petrosyan, A.Balayan The book is designed by: M. Avetisyan All the rights of the author are reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of the author or the publisher.

ISBN 978-9939-65-057-9 ©YSMU, after M. Heratsi, 2013

C o n t e n t s

Introduction ...... 9 Section 1: What is Ethics and How does it Help Doctors? ...... 11 Section 2: Does Ethics Change During Time? ...... 18 Section 3: How do Individuals Decide What is Moral? ...... 23 Section 4: The Subjects, problems and Prehistory of Bioethics ..... 30 Section 5: Theoretical Foundations and Historical Stages of Development of Bioethics ...... 39 Section 6: Historical Models of Bioethics and Types of Doctor-Patient Relationships ...... 51 Section 7: Doctor’s Duties and Patient’s Rights ...... 58 Section 8: Doctors’ Etiquette ...... 63 Section 9: Involuntary Hospitalization and Sterilization of Mentally Ill People ...... 66 Section 10: Informed consent ...... 74 Section 11: Moral and Legal Issues of Abortion ...... 76 Section 12: Ethical Issues of Genetic Engineering and Cloning .... 80 Section 13: Issues of Life and Death: Euthanasia ...... 90 Section 14: Euthanasia. Issues of Sociology of Life ...... 95 Section 15: Euthanasia in Armenia ...... 109 Section 16: Palliative Care ...... 115 Section 17: Armenian Medieval Philosophy and Medical Science: Narek as a Remedy ...... 120 Section 18: Social Justice and Health Policy ...... 131 Section 19: Medical Cases and Practical Solutions ...... 139 Appendix ...... 144 Sample Tests 144 Self Work Topics ...... 148 Glossary of Bioethical Terms ...... 180 Literature 185

Acknowledgement

I consider it my privilege to thank sincerely to all the specialists who have shared their valuable comments regarding the manuscript of this work and who have supported the publication of this book by their useful advices. Special thanks to: Holder of UNESCO Chair in Bioethics, President of World Associasion of Medical Law, professor Amnon Carmi (Israel) Professor of Sechenov Medical Academy M.Yu. Yarovinski Founding President of the Forum of Ethical Committees of CIS Countries Professor O. I. Kubar, M.D. (Saints-Petersburg), Professor T.V. Mishatkina (Minsk) Academician B. N. Yudin M.D (Moscow). Editor of “Journal of Armenian Medical Abstracts” professor R.A. Hovhannisyan M.D. (Yerevan), Head of the chair of Philosophy of NAS of RA M.A. Harutyunyan PhD (Yerevan). Professor M. Valton (Australia) Professor R.A. Apresyan Head of the Chair of Ethics of Institute of Philosophy of NAS, RF Professor Henk Ten Have, USA The author will be redy to accept all the comments and suggestions, which will help to elluminate the shortcomings of this work if the God permits me to republish this book again.

A letter of praise from UNESCO Chair in Bioethics

I would like to highlight the important role of Prof. Susanna Davtyan, who functions as the Head of the Armenian Unit of the International Network of the UNESCO Chair in Bioethics, in addition to her local post as the Head of the Philosophy Chair of YSMU (2006-2009). 11 years ago the UNESCO Chair in Bioethics held its second international conference on “Ethics Education in Medical School” in Eilat (Israel). Prof. S. Davtyan took an active part in this international event, and her interesting report was regarded by all the participants as an important presentation. Her successful participation started an ongoing exchange of thoughts and close contact with the Directors of the UNESCO Chair. After the 7th European Academy on Bioethics in Germany, and the international conference on “ Ethics Committees in Hospitals” organized by the UNESCO Chair in Bioethics ( Israel), and as a result of her hard and creative work she was appointed as a Head of the Armenian Unit of International Net- work of UNESCO Chair in Bioethics(2008). The fact that she was appointed as a Chair of Scientific Session “Teach- ing Methodology” (Israel 2010) and “Bioethics Education- Local Experience” (Singapore 2011), reflects the high appreciation shown to her by the international forum. In the international conference held 22-30, May 2011, in Singapore, prof. S. Davtyan reported on “Methodology and Methods of Investigating Bioethics (Experimental Course of Bioethics based on Basic Educational Program of UNESCO”’). Her report got high praise by well-known participants, and it was recommended to deliver it to the Headquarters of UNESCO in Paris. The UNESCO Chair is authorized to promote the study and education of bioethics in medical schools all over the world. In order to achieve this aim the

Chair encourages the production of books on medical ethics for the benefit of both teachers and the students. The well written book of prof. S. Davtyan is regarded by the Chair as an important contribution to the Armenian academic world. Its English translation allows readers from other countries to be ac- quainted with the ethical and legal norms that prevail in Armenia, with the thoughts, view, ideas of medieval Armenian thinkers relating to the problems of life and death, good and evil, sins and illnesses. It gives me great pleasure to express my appreciation and thanks to our Armenian colleague for excellent preparation of her report in the conference in Tiberias ( 02.09.2012) and about her report in the meeting of Heads of Na- tional Units ( 05/09/2012). I shall appreciate and be thankful if you would share with me the appreciation and will offer Prof. Davtyan your generous support in order to enable her to advance the education of bioethics in your university and throughout your country. Once again please allow me to wish you a future professional success.

Prof. Amnon Carmi, Head of The UNESCO Chair in Bioethics. President of The World Association of Medical Law

Letter of praise from Forum of Ethical Committees of CIS Countries

Following the Western and Russian example, 12 years ago YSMU started to teach Bioethics to its students. The head of the chair of Philosophy S.H. Davtyan regularly participates in activities of the committee organized under the auspices of UNESCO, reports in international conferences, cooperates with major centers of Bioethics including the centers in St. Petersburg, Moscow, Zagreb, Tartu, Haifa and corresponding chairs of other medical universities. H.S. Davtyan was invited in 2005 by UNESCO as an expert to participate in regional consultation on Bioethics and she co-chaired the fourth session of the consultation with Academician B.G. Yudin PhD, and Professor T.V. Mishatkina. I was convinced the this first manual in the national language will put a start for future publications, which will help the public to gain necessary Bio- ethical knowledge. The handout is pleasantly outstanding with the fact that it presents both international and Armenian legal acts on Bioethics. The book presents the medical thoughts of medieval Armenian thinkers (Narekatsi, Davit the Invin- cible etc.). The theoretical material is enriched by the results of sociological surveys conducted among the students and university professors. The handout also includes issues of applied ethics, case studies collected from all over the world and their ethical analysis. These cases will both enrich students’ thoughts and endow them with skills of bioethical analysis. In 2007 S. H. Davtyan participated in the international scientificconference dedicated to the activities of ethical committees and bioethical education. Dur- ing the conference the “Ethical Review of Biomedical Research in the CIS Countries (Social and Cultural Aspects) book was presented in Russian and English. The book includes S. H. Davtyan’s article which presentes the educational status of Bioethics, its historical and cultural bases, the legal and normative mechanisms for regulating bioethical issues and the present and prospec- tive forms of international cooperation. It is my pleasure to notes that the rector of YSMU gives due reverence the importance of the subject and to productive work of Mrs. S. H. Davtyan in the process of raising a medical practitioner who matches the demands of our time. I wish good luck to this interesting handout!

Professor O. I. Kubar MD, Founding President of Forum of Ethical Committees of CIS Countries

Letter of Praise from NAS of Russian Federation

Article 19, point 4 of General Declaration on Human Rights (adopted by 33-rd session of UNESCO General Assembly on October 19, 2005) urges to” foster debate, education and public awareness, and engagement in bioethics.” The purpose for widely spreading humanistic ideas of Bioethics is to awaken the “conscience of a specialist” among doctors which will hold them back from the unwise idea of creating a human creature by genetic engineering or cloning technologies. Today, it is a necessity to spread the humanistic bioethical concepts among the public because it will solve a range of complicated issues which have risen as a result of science. The science leads the society towards the verge of an abyss threatening to destroy the whole humankind. And these are not mere words, this is the reality. This is exactly why, it is necessary to create or awaken the moral and legal consciousness of a doctor-scientist. Anyone who teaches Bioethics must be outstanding not only with his/her encyclopedic knowledge, sensitivity, humanism and general education, but also with strong moral convictions. In this regard, I do encourage the publication of S.H. Davtyan’s book. I am convinced it will be helpful not only for students but for shaping the bioethical conciseness of the population of RA.

B.G. Yudin PhD, academician, Director Institute of Humanity of NAS of RF

Introduction

With Hippocrates you will become not only a good doctor, but also a good man. Mudrov

There are more than enough books written on Bioethics. High quality texts in English and other foreign languages are available both elec- tronically and in print. We have decided to compile this one with the anticipation that it will help you, dear student, to get a better insight into intriguing and important issues of Bioethics. These articles are compiled from the Internet resources, as well as works and manuals of famous research institutions of Bioethics. Some contemporary and ongoing Bioethics research projects are presented in the book. Thus, we are sure that it will be an interesting and useful tool for discovering the world of Bioethics, the thoughts and ideas of Medi- eval Armenian thinkers concerning the problems of Bioethics, as well as ethical and legal norms prevailry in the world and particularly in Armenia. The term Bioethics, as other terms denoting fields of research or study, such as Marketing, Sociology or Philosophy, has numerous meanings. The term Bioethics is sometimes used as the study of moral attitude humans should have towards the environment, or all living creatures. However, in the text below, it will be used as a synonym of medical ethics. The handout is divided into 19 sections each addressing a particular topic.

The Appendix section presents some international documents and texts widely known among specialists of medical ethics as well as practicing doctors around the world. The complete texts of the Hippocratic Oath, The Declaration of Geneva, Declaration of Tokyo and other papers are presented. A few reading materials, including a summary of Narek as a remedy, an extract from Leo Alexander’s famous article as well as an article from S. H. Davtyan is included in the book. A complete bibliography of all cited sources is provided at the end of the book. This manual is the first in its kind published by the chair of philosophy at Yerevan State Medical University and will be improved in the future. Thus, your feedback and constructive comments are most wel- come for the author of the manual.

SECTION 1

WHAT IS ETHICS AND HOW DOES IT HELP DOCTORS

*** After completing this section you should be able to: a. Understand what is Ethics. b. Describe main issues of Ethics. c. Describe main issues of development of Ethics. d. Define ethical cognitivism e. Define ethical emotivism

Subject matter of Ethics Ethics is allegedly one of the three main branches of philosophy. Together with ontology (Philosophy of existence) and epistemology (Philosophy of knowledge) Ethics (Philosophy of human conduct) forms the core of philosophy. As such Ethics has had a long history of over 2500 years. First ideas of ethics have emerged in Ancient Greece. At the beginning Ethics emerged as a set of wise sayings of wing- words such as “Know yourself”, a phrase allegedly found on the en- trance of Delphi temple in ancient Greece. Later, issues of proper conduct have been discussed by Plato in his dialogues, who apparently discusses these issues with his teacher, Soc- rates on the one hand, and with his contemporaries on the other. Plato discusses important issues such as the hierarchy of ethical norms, the essence of values (heroism, good, love etc.), however Ethics as a sepa- 11

WWhhaatt iiss EEtthhiiccss aanndd HHooww ddooeess iitt rate branch of knowledge did not exist until Plato’s student, probably his best student, Aristotle created his famous writings: “Nichomachean Ethics” and “Big Ethics” (28). It is believed that Nichomach was Aristotle’s father, a royal doctor and Aristotle intended to describe his father’s behavior (The word “ethics” is translated as behavior from Greek), later the term ethic lost its original meaning and attained the connotation of a desirable behavior, and not just any behavior. Ethics as a science is often defined as a science or a discipline that studies the socially acceptable, moral or simply correct norms of human behavior. As such it discusses purely personal (moral), interpersonal (relationship between two people) and social (relationship between groups or between an individual and a group) issues. These issues are seldom treated in isolation and most of the time are considered to be deeply interrelated. An example of purely personal issue is the meaning of an individual’s life. What is the meaning of my life? Why do I live? Why was I born? Was I born simply because of a biological incident? Was I born simply because two individuals decided to enrich their lives by giving birth to a child? Or, was I born because an almighty God decided to give me a birth for a particular mission? Are there any specific tasks I need to accomplish in my life? All these, as we see, require an individual to think about the moral coordinates of his Subject, of his Self in this universe. An example of interpersonal issues is the issue of justice. What is justice? When someone pays an X amount and purchases a Y amount of food. How do we know that this exchange was an example of just exchange? Or when someone works the whole day, say building a house and receives some amount of money. How do we know if the person was paid a just amount of salary? Do we simply look around and compare his/her salary, and claim that it was just if other people have also received the same amount of money and claim that it was unjust if this is not the case? Or we simply look inside and try to come to a conclusion simply relying to our inner feelings? An example of social issues is the issue of power. What is social power? Who should be the ruler? Why? Why should anyone rule over the others? Should people be equal? Are they equal? What is better

12 social order democracy or dictatorship? What is preferable, being a militarist of pacifist? Etc. The answers to these and other issues have changed during the time. Ethics is sometimes separated into metaethics, normative ethics and applied ethics. The few paragraphs below are adopted from Internet Encyclopedia of Philosophy and provide descriptions of these units of ethics. 1. Metaethics The term "meta" means after or beyond, and, consequently, the notion of metaethics involves a removed, or bird's eye view of the entire project of ethics. We may define metaethics as the study of the origin and meaning of ethical concepts. When compared to normative ethics and applied ethics, the field of metaethics is the least precisely defined area of moral philosophy. It covers issues from moral semantics to moral epistemology. Two issues, though, are prominent: (1) metaphysical issues concerning whether morality exists independently of humans, and (2) psychological issues concerning the underlying mental basis of our moral judgments and conduct. a. Metaphysical Issues: Objectivism and Relativism Metaphysics is the study of the kinds of things that exist in the universe. Some things in the universe are made of physical stuff, such as rocks; and perhaps other things are nonphysical in nature, such as thoughts, spirits, and gods. The metaphysical component of metaethics involves discovering specifically whether moral values are eternal truths that exist in a spirit-like realm, or simply human conventions. There are two general directions that discussions of this topic take, one other-worldly and one this-worldly. This idea will be further elaborated in the next chapter. b. Psychological Issues in Metaethics A second area of metaethics involves the psychological basis of our moral judgments and conduct, particularly understanding what moti- vates us to be moral. We might explore this subject by asking the simple question, "Why be moral?" Even if I am aware of basic moral standards, such as don't kill and don't steal, this does not necessarily mean that I will be psychologically compelled to act on them. Some answers to the question "Why be moral?" are to avoid punishment, to gain praise, to attain happiness, to be dignified, or to fit in with society.

i. Emotion and Reason A second area of moral psychology involves a dispute concerning the role of reason in motivating moral actions. If, for example, I make the statement "abortion is morally wrong," am I making a rational assessment or only expressing my feelings? On the one side of the dispute, 18th century British philosopher David Hume argued that moral assessments involve our emotions, and not our reason. We can amass all the reasons we want, but that alone will not constitute a moral assessment. We need a distinctly emotional reaction in order to make a moral pronouncement. Reason might be of service in giving us the relevant data, but, in Hume's words, "reason is, and ought to be, the slave of the passions." Inspired by Hume's anti-rationalist views, some 20th century philosophers, most notably A.J. Ayer, similarly denied that moral assessments are factual descriptions. For example, although the statement "it is good to donate to charity" may on the surface look as though it is a factual description about charity, it is not. Instead, a moral utterance like this involves two things. First, I (the speaker) I am expressing my personal feelings of approval about charitable donations and I am in essence saying "Hooray for charity!" This is called the emotive element in so far as I am expressing my emotions about some specific behavior. Second, I (the speaker) am trying to get you to donate to charity and am essentially giving the command, "Donate to charity!" This is called the prescriptive element in the sense that I am prescribing some specific behavior. From Hume's day forward, more rationally-minded philosophers have opposed these emotive theories of ethics (see non-cognitivism in ethics) and instead argued that moral assessments are indeed acts of reason. 18th century German philosopher Immanuel Kant is a case in point. Although emotional factors often do influence our conduct, he argued, we should nevertheless resist that kind of sway. Instead, true moral action is motivated only by reason when it is free from emotions and desires. A recent rationalist approach, offered by Kurt Baier (1958), was proposed in direct opposition to the emotivist and prescriptivist theories of Ayer and others. Baier focuses more broadly on the reasoning and argumentation process that takes place when making moral choices. All of our moral choices are, or at least can be, backed by some reason or justification. If I claim that it is wrong to steal

14 someone's car, then I should be able to justify my claim with some kind of argument. For example, I could argue that stealing Smith's car is wrong since this would upset her, violate her ownership rights, or put the thief at risk of getting caught. According to Baier, then, proper moral decision making involves giving the best reasons in support of one course of action versus another. 2. Normative Ethics Normative ethics involves arriving at moral standards that regulate right and wrong conduct. In a sense, it is a search for an ideal litmus test of proper behavior. The Golden Rule is a classic example of a normative principle: We should do to others what we would want others to do to us. Since I do not want my neighbor to steal my car, then it is wrong for me to steal her car. Since I would want people to feed me if I was starving, then I should help feed starving people. Using this same reasoning, I can theoretically determine whether any possible action is right or wrong. So, based on the Golden Rule, it would also be wrong for me to lie to, harass, victimize, assault, or kill others. The Golden Rule is an example of a normative theory that establishes a single principle against which we judge all actions. Other normative theories focus on a set of foundational principles, or a set of good character traits. The key assumption in normative ethics is that there is only one ultimate criterion of moral conduct, whether it is a single rule or a set of principles. Three strategies will be noted here: (1) virtue theories, (2) duty theories, and (3) consequentialist theories. Which will be treated in chapters below. 3. Applied Ethics Applied ethics is the branch of ethics which consists of the analysis of specific, controversial moral issues such as abortion, animal rights, or euthanasia. In recent years applied ethical issues have been subdivid- ed into convenient groups such as medical ethics, business ethics, environmental ethics, and sexual ethics. Generally speaking, two features are necessary for an issue to be considered an "applied ethical issue." First, the issue needs to be controversial in the sense that there are significant groups of people both for and against the issue at hand. The issue of drive-by shooting, for example, is not an applied ethical issue, since everyone agrees that this practice is grossly immoral. By contrast,

15 the issue of gun control would be an applied ethical issue since there are significant groups of people both for and against gun control. The second requirement for in issue to be an applied ethical issue is that it must be a distinctly moral issue. On any given day, the media presents us with an array of sensitive issues such as affirmative action policies, gays in the military, involuntary commitment of the mentally impaired, capitalistic versus socialistic business practices, public versus private health care systems, or energy conservation. Although all of these issues are controversial and have an important impact on society, they are not all moral issues. Some are only issues of social policy. The aim of social policy is to help make a given society run efficiently by devising conventions, such as traffic laws, tax laws, and zoning codes. Moral issues, by contrast, concern more universally obligatory practices, such as our duty to avoid lying, and are not confined to individual societies. Frequently, issues of social policy and morality overlap, as with murder which is both socially prohibited and immoral. However, the two groups of issues are often distinct. For example, many people would argue that sexual promiscuity is immoral, but may not feel that there should be social policies regulating sexual conduct, or laws punishing us for promiscuity. Similarly, some social policies forbid residents in certain neighborhoods from having yard sales. But, so long as the neighbors are not offended, there is nothing immoral in itself about a resident having a yard sale in one of these neighborhoods. Thus, to qualify as an applied ethical issue, the issue must be more than one of mere social policy: it must be morally relevant as well. In theory, resolving particular applied ethical issues should be easy. With the issue of abortion, for example, we would simply determine its morality by consulting our normative principle of choice, such as act- utilitarianism. If a given abortion produces greater benefit than disbenefit, then, according to act-utilitarianism, it would be morally acceptable to have the abortion. Unfortunately, there are perhaps hun- dreds of rival normative principles from which to choose, many of which yield opposite conclusions. Thus, the stalemate in normative ethics between conflicting theories prevents us from using a single decisive procedure for determining the morality of a specific issue. The usual solution today to this stalemate is to consult several representative

16 normative principles on a given issue and see where the weight of the evidence lies. Why do we need Bioethics in addition to general ethics?1 General ethics concentrates on global problems of human conduct. Some questions of general ethics are: What is the origin of moral norms? Are there moral norms? Is there only one set of moral norms or are there many sets? etc. Humans though, and particularly, practicing physicians though, need not concentrate on theoretical aspects of ethics, but rather they need specific guidelines for acting in specific social settings. The general principles are seldom useful in similar situations. For example, the principle “Do Good” does not help much when deciding whether medical secrets should be revealed or not. This is partly because the word “Good” is ambiguous. Some physicians can judge that telling the truth is good, others, on the other hand, may judge that hiding negative facts will help patients and hence is the real good. The general principles are in fact, too general to be applied in specific social settings.

Exercises and review questions a. What is metaethics? b. What is normative ethics? c. What is applied ethics? d. What is emotivism in ethics?

1 Medical Ethics Manual by World Medical Association, France, 2005, pp. 10- 11 17

SECTION 2

DOES ETHICS CHANGE DURING TIME?

*** After completing this chapter you should be able to: a. Define ethical relativism. b. Define ethical absolutism. c. Describe major values of Western ethics. d. Describe major values of Eastern ethics.

Objectivism (Absolutism) and Relativism of ethical norms As mentioned in the chapter above, one of central meta-ethical issues is the related to the character of ethical norms. Are they objective and absolute as mathematical terms say, or are they relative and change from time to time. The following paragraph, from the Internet Ency- clopedia of Philosophy, provide a good illustration of this issues2: Pro- ponents of the other-worldly view typically hold that moral values are objective in the sense that they exist in a spirit-like realm beyond subjective human conventions. They also hold that they are absolute, or eternal, in that they never change, and also that they are universal inso- far as they apply to all rational creatures around the world and throughout time. The most dramatic example of this view is Plato, who was inspired by the field of mathematics. When we look at numbers and mathematical relations, such as 1+1=2, they seem to be timeless concepts that never change, and apply everywhere in the universe. Humans do not invent numbers, and humans cannot alter them. Plato explained the eternal character of mathematics by stating that they are abstract entities that exist in a spirit-like realm. He noted that moral values also

2 Ethics, Internet Encyclopedia of Philosophy, http://www.iep.utm.edu/e/ethics.htm, September 2009. 18 are absolute truths and thus are also abstract, spirit-like entities. In this sense, for Plato, moral values are spiritual objects. Medieval philosophers commonly grouped all moral principles together under the head- ing of "eternal law" which were also frequently seen as spirit-like objects. 17th century British philosopher Samuel Clarke described them as spirit-like relationships rather than spirit-like objects. In either case, though, they exist in a sprit-like realm. A different other-worldly approach to the metaphysical status of morality is divine commands issu- ing from God's will. Sometimes called voluntarism (or divine command theory), this view was inspired by the notion of an all-powerful God who is in control of everything. God simply wills things, and they become reality. He wills the physical world into existence, he wills human life into existence and, similarly, he wills all moral values into existence. Proponents of this view, such as medieval philosopher William of Ockham, believe that God wills moral principles, such as "murder is wrong," and these exist in God's mind as commands. God informs humans of these commands by implanting us with moral intuitions or revealing these commands in scripture. The second and more this-worldly approach to the metaphysical status of morality follows in the skeptical philosophical tradition, such as that articulated by Greek philosopher Sextus Empiricus, and denies the objective status of moral values. Technically, skeptics did not reject moral values themselves, but only denied that values exist as spirit-like objects, or as divine commands in the mind of God. Moral values, they argued, are strictly human inventions, a position that has since been called moral relativism. There are two distinct forms of moral relativism. The first is individual relativism, which holds that individual people create their own moral standards. Friedrich Nietzsche, for example, argued that the superhuman creates his or her morality distinct from and in reaction to the slave-like value system of the masses. The second is cultural relativism which maintains that morality is grounded in the approval of one's society - and not simply in the preferences of individual people. This view was advocated by Sextus, and in more recent centuries by Michel Montaigne and William Graham Sumner. In addition to espousing skepticism and relativism, this-worldly approaches to the metaphysical status of morality deny the absolute and universal nature of morality and hold instead that moral values in fact change from soci-

19 ety to society throughout time and throughout the world. They frequently attempt to defend their position by citing examples of values that differ dramatically from one culture to another, such as attitudes about polygamy, homosexuality and human sacrifice. Western and Eastern Ethics It is well known that Europe on the one hand and the East (China, India and Japan) on the other hand have very different cultures and value systems. It is often said that they form two distinct civilizations which are on the verge of clashing. Thus it would be beneficial to get familiar with some key differences these two cultures have in the field of medical ethics. The text below is adopted from Brian Benjamin Carter (60) Both cultures developed ethics as an extension of becoming 'professions.' Traditionally, the three learned (scholarly) professions are law, religion, and medicine. These are callings to which are trusted "the most private and intimate secrets of a person's mind, soul, and body" (Lundberg). Ancient China was much less socially grouped than ancient Greece. In the Middle Ages of the West, political and social groups were very important. Doctors organized unions voluntarily. They developed ap- prenticeships and tried to avoid internal competition. While the West constructed social codes, China emphasized personal virtue. The Confucian concept of benevolence is similar to the Hippocratic 'do no harm.' In fact, there are many parallels between the AMA's revised principles (which is the latest outgrowth of thousands of years of Western philosophy and medicine) and Chinese medical ethics. Western Civilization was inherently more likely to develop a set of ethical guidelines than Chinese culture. Western civilization and its religions are highly legislative and literal. It creates guidelines which are fixed, absolute, and eternal. These guidelines are often kept in a book or document such as the Bible, the U.S. Constitution, or the AMA's Prin- ciples of Medical Ethics. In China, Taoist natural spontaneity, Buddhist sudden enlightenment and Confucian self-cultivation combined to repel the idea of absolute standards. Of course, this is not wholly true; Christian "living in the Spirit" can be totally spontaneous, Jesus was a homeless wanderer led by God, Buddhism has 4 noble truths and an 8-fold path, Confucius

20 wrote the Analects, and Lao Tzu wrote the Tao Te Ching (an oxymoron - the way that cannot be named can be written in a book?).

A Table of Comparisons between Western and Chinese Medical Ethics Western Chinese The AMA's Revised Principles of Medical Medical Medical Ethics, June 2001 Ethics Ethics History History A physician shall be dedicated to The Sense of Hippocrates, providing competent medical care, with Pity, The Nurenberg, compassion and respect for human dig- Sense of Geneva nity and rights. Shame A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to re- Hippocrates, The Sense of port physicians deficient in character or Percival Shame competence, or engaging in fraud or deception, to appropriate entities. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which AMA --- are contrary to the best interests of the patient. A physician shall respect the rights of patients, colleagues, and other health The Sense of professionals, and shall safeguard pa- Hippocrates Respect tient confidences and privacy within the constraints of the law. A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to Nurenberg, Self-cultivation medical education, make relevant in- AMA formation available to patients, colleagues, and the public, obtain consul-

21 tation, and use the talents of other health professionals when indicated. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom 3 Percival The 6 Taboos to serve, with whom to associate, and the environment in which to provide medical care. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the AMA Benevolence community and the betterment of public health. The Sense of A physician shall, while caring for a Hippocrates, Shame, The patient, regard responsibility to the pa- Helsinki Sense of Re- tient as paramount. spect A physician shall support access to Hippocrates, Benevolence medical care for all people. Geneva

Exercises and review questions a. What is moral objectivism? b. What is moral relativism? c. What is the principle of benevolence? d. Why do you think the Western and Eastern ethics differ? e. Why do you think that spontaneity or sudden enlightenment are considered so important in the East and “neglected” in the West?

* One popular doctor, Bian Que set forth the earliest code of medical ethics in China, The 6 Taboos. "Medicine should not be offered in six circumstances… to: a) People who had unreasonable arrogance and indulgence, b) People who appreciated riches more than life, c) People who couldn't even keep body and soul together, d) People who were suffering from interlocking Yin and Yang, e) People who were too weak to take medicines, and f) People who didn't believe in medicine but in sorcery." 22

SECTION 3

HOW DO INDIVIDUALS DECIDE WHAT IS MORAL?

*** After completing this chapter you should be able to: a. Understand what is moral decision making. b. Understand the utilitarian approach in moral decision making. c. Understand what is common good. d. Understand what is virtue approach in moral decision making.

Methods of Moral Decision Making The text below is adopted by an article by Manuel Velasquez, Clair Andre, Thomas Shanks, and Michael Mayer (76). Moral issues are everywhere. We are bombarded daily with questions about the justice of our foreign policy, the morality of medical technologies that can prolong our lives, the rights of the homeless, the fairness of our children's teachers to the diverse students in their class- rooms. Dealing with these moral issues is often perplexing. How, exactly, should we think through an ethical issue? What questions should we ask? What factors should we consider? The first step in analyzing moral issues is obvious but not always easy: Get the facts. Some moral issues create controversies simply because we do not bother to check the facts. This first step, although obvious, is also among the most important and the most frequently over- looked.

But having the facts is not enough. Facts by themselves only tell us what is; they do not tell us what ought to be. In addition to getting the facts, resolving an ethical issue also requires an appeal to values. Phi- losophers have developed five different approaches to values to deal with moral issues. These approaches are the utilitarian approach, the rights approach, the fairness or justice approach, the common good approach and the virtue approach. These approaches are briefly described below. The Utilitarian Approach Utilitarianism is often considered to be a branch of consequentalism. Consequentalism is the belief, that the rationality of an action depends on its possible consequences. If an action leads to good consequences, than the action is moral, otherwise it is considered to be immoral. Utilitarianism was conceived in the 19th century by Jeremy Ben- tham and John Stuart Mill to help legislators determine which laws were morally best. Both Bentham and Mill suggested that ethical actions are those that provide the greatest balance of good over evil. To analyze an issue using the utilitarian approach, we first identify the various courses of action available to us. Second, we ask who will be affected by each action and what benefits or harms will be derived from each. And third, we choose the action that will produce the greatest benefits and the least harm. The ethical action is the one that provides the greatest good for the greatest number. The Rights Approach The second important approach to ethics has its roots in the philosophy of the 18th-century thinker Immanuel Kant and others like him, who focused on the individual's right to choose for herself or himself. According to these philosophers, what makes human beings different from mere things is that people have dignity based on their ability to choose freely what they will do with their lives, and they have a fundamental moral right to have these choices respected. People are not objects to be manipulated; it is a violation of human dignity to use people in ways they do not freely choose. Of course, many different, but related, rights exist besides this basic one. These other rights (an incomplete list below) can be thought of as different aspects of the basic right to be treated as we choose.

• The right to the truth: We have a right to be told the truth and to be informed about matters that significantly affect our choices. • The right of privacy: We have the right to do, believe, and say whatever we choose in our personal lives so long as we do not violate the rights of others. • The right not to be injured: We have the right not to be harmed or injured unless we freely and knowingly do something to deserve punishment or we freely and knowingly choose to risk such injuries. • The right to what is agreed: We have a right to what has been promised by those with whom we have freely entered into a contract or agreement. In deciding whether an action is moral or immoral using this second approach, then, we must ask, Does the action respect the moral rights of everyone? Actions are wrong to the extent that they violate the rights of individuals; the more serious the violation, the more wrongful the action. Another approach that was elaborated by Immanuel Kant is the de- ontological approach. Deontology is the meta-ethical discipline which claims that a human being is moral if he/she does his duty. Unless the action is implemented to perform one’s duty, it is not moral. If an action is done for pleasure, or for gain etc. it cannot be considered to be moral. The Fairness or Justice Approach The fairness or justice approach to ethics has its roots in the teach- ings of the ancient Greek philosopher Aristotle, who said that "equals should be treated equally and unequals unequally." The basic moral question in this approach is: How fair is an action? Does it treat everyone in the same way, or does it show favoritism and discrimination? Favoritism gives benefits to some people without a justifiable reason for singling them out; discrimination imposes burdens on people who are no different from those on whom burdens are not imposed. Both favoritism and discrimination are unjust and wrong. The Common-Good Approach This approach to ethics assumes a society comprising individuals whose own good is inextricably linked to the good of the community.

Community members are bound by the pursuit of common values and goals. The common good is a notion that originated more than 2,500 years ago in the writings of Plato, Aristotle, and Cicero. More recently, contemporary ethicist John Rawls defined the common good as "certain general conditions that are...equally to everyone's advantage." In this approach, we focus on ensuring that the social policies, social systems, institutions, and environments on which we depend are beneficial to all. Examples of goods common to all include affordable health care, effective public safety, peace among nations, a just legal system, and an unpolluted environment. Appeals to the common good urge us to view ourselves as members of the same community, reflecting on broad questions concerning the kind of society we want to become and how we are to achieve that society. While respecting and valuing the freedom of individuals to pursue their own goals, the common-good approach challenges us also to recognize and further those goals we share in common. The Virtue Approach The virtue approach to ethics assumes that there are certain ideals toward which we should strive, which provide for the full development of our humanity. These ideals are discovered through thoughtful reflection on what kind of people we have the potential to become. Virtues are attitudes or character traits that enable us to be and to act in ways that develop our highest potential. They enable us to pursue the ideals we have adopted. Honesty, courage, compassion, generosity, fi- delity, integrity, fairness, self-control, and prudence are all examples of virtues. Virtues are like habits; that is, once acquired, they become characteristic of a person. Moreover, a person who has developed virtues will be naturally disposed to act in ways consistent with moral principles. The virtuous person is the ethical person. In dealing with an ethical problem using the virtue approach, we might ask, What kind of person should I be? What will promote the development of character within myself and my community?

Ethical Problem Solving These five approaches suggest that once we have ascertained the facts, we should ask ourselves five questions when trying to resolve a moral issue: • What benefits and what harms will each course of action produce, and which alternative will lead to the best overall consequences? • What moral rights do the affected parties have, and which course of action best respects those rights? • Which course of action treats everyone the same, except where there is a morally justifiable reason not to, and does not show favoritism or discrimination? • Which course of action advances the common good? • Which course of action develops moral virtues? This method, of course, does not provide an automatic solution to moral problems. The method is merely meant to help identify most of the important ethical considerations. In the end, we must deliberate on moral issues for ourselves, keeping a careful eye on both the facts and on the ethical considerations involved. Moral decision making from personal point of view The ideas below are adopted from the “Medical Ethics Manual” by the Worls Medical Association. For individual physicians and medical students, medical ethics does not consist simply following the recommendations of an authority. These recommendations are usually general in nature and individuals need to determine whether or not they apply to the situation at hand. Moreover, many ethical issues arise in medical practice for which there is no guidance from medical associations. Individuals are ultimately responsible for making their own ethical decisions and for implement- ing them. There are different ways of approaching ethical issues as described above. The approaches to moral decision making can be separated also into rational and non-rational methods. Let us discuss these methods in detail separately. Non-rational approaches: 1. Obedience is a common way of making ethical decisions, especially by children and those who work within authoritarian structures

(e.g. the military, police, some religious organizations, many business- es). Morality consists in following the rules or instructions of those in authority, whether or not you agree with them. 2.Imitation is similar to obedience in that it subordinates one’s judgment about right and wrong to that of another person, in this case, a role model. Morality consists in following the example of the role model. This has been perhaps the most common way of learning medical ethics by aspiring physicians, with the role models being the senior consultants and the mode of moral learning being observation and as- similation of the values portrayed. 3.Feeling or desire is a subjective approach to moral decision making and behavior. What is right is what feels right or satisfies one’s desire; what is wrong is what feels wrong or frustrates one’ desire. The measure of morality is to be found within each individual and, of course, can vary greatly from one individual to another, and even within the same individual over time. Intuition is an immediate perception of the right way to act in a situation. It is similar to desire in that it is entirely subjective; however, it differs because of its location in the mind rather than the will. To that extent it comes closer to the rational forms of ethical decision-making than do obedience, imitation, feeling and desire. However, it is neither systematic nor reflexive but directs moral decisions through a simple flash of insight. Like feeling and desire, it can vary greatly from one individual to another, and even within the same individual over time. Habit is a very efficient method of moral decision-making since there is no need to repeat a systematic decision-making process each time a moral issue arises similar to one that has been dealt with previously. However, there are bad habits (e.g. lying) as well as good ones (e.g. truth-telling); moreover, situations that appear similar may require significantly different decisions. As useful as habit is, therefore, one cannot place all one’s confidence in it. Rational approaches As the study of morality, ethics recognizes the prevalence of these non-rational approaches to decision-making and behavior. However, it is primarily concerned with rational approaches. Four such approaches are deontology, consequentalism, principlism and virtue ethics. These approaches were presented above and will not be discussed here. Alt-

28 hough the name principlism reflects the essence of this approach, it worth to state here that principlism uses ethical principles as the basis for making moral decision. It applies these principles to particular cases or situations in order to determine what is the right thing to do, taking into account both rules and consequences. Principlism has been very influential in recent ethical debates especially in the USA. Four principles in particular, respect for autonomy, beneficence, non- maleficence and justice, have been identified as the most important for ethical decision-making in medical practice.

Exercises and review questions a. When did the utilitarian approach emerge? b. Who is the originator of the rights approach for moral decision making? c. What is a rational method for moral decision making? d. What is a decision making by intuition? e. What method of moral decision making do you use most often? f. What is consequentalism?

SECTION 4

THE SUBJECT, PROBLEMS AND PREHISTORY OF BIOETHICS

*** After reading this chapter, you should be able to: • understand how Bioethics came to exist historically • understand what Bioethics is • understand what questions Bioethics answers • why is it necessary to study Bioethics

The first undertaking we have, is to understand what bioethics is, what are the questions it tries to answer, what are the methods it uses, what does it say, in addition to other fields of study and what is the scope of the subject. Let us consider each of these questions independently.

What is Bioethics? As is obvious from the word “Bioethics” it has two roots: Bio – meaning life and Ethics which stands for behavior in ancient Greek. The term “Bioethics” was first used by Van Ranseller Potter, an Ameri- can biochemist. Little doubt can be cast on the belief that humans are the most valuable creatures on this planet, at least for humans themselves, however, mankind registered a few instances when “picking the fruits that the nature has” stabbed a knife from behind in a longer run. Here are a few examples:

a. physicists invented the nuclear weapon at the beginning of the 20th century which eventually caused mass distractions in Japan at the end of the World War II, b. scientists invented more efficient means for mining oil and coil and it caused global warming c. mass agriculture and urbanization damaged the wild life, etc. Similar inventions gradually maturated the need for creating a discipline that would address these needs. This science came to be known as Bioethics, the discipline which studies the attitude, the behavior humans should adopt when dealing with their oykos. The World War II, in addition to major economic crisis, had a hu- mongous influence on European culture and moral thought. As such, Bioethics, among other new humanitarian disciplines, emerged after the World War II. Initially, bioethics aimed at becoming a new wisdom which would combine humanitarian and scientific knowledge and put knowledge into service for the well being of mankind, later however, it was seg- mented into two parts: - one part maintained the term Bioethics, but gradually focused on ethical problems in Medicine and - The other part focused on moral aspects of application of science and on responsible attitude towards nature, came be known as Envi- ronmentalism and became a new branch of traditional Ethics.

The first country from the former USSR that incorporated courses of Bioethics into all its medical institutions was Russia (1995). Yerevan State Medical University started to teach Bioethics from year 2000. Today, other universities in Armenia include is Bioethics into their mandatory courses. The rapid geographic expansion of Bioethics owes credit to a few major incidents (6). The first to be mentioned is certainly the inhuman medical experimentation on war prisoners conducted by Nazi doctors.

Nuremberg Tribunal The Nurenberg Tribunal discovered the terrible experiments on war prisoners of Nazi Germany and the physicians’ participation in it. The

Nuremberg Tribunal also discovered that human beings are absolutely unprotected from similar violations. This eventually brought forward the Nurenberg Code, which you may find in the appendix of this manual. Below a very succinct timeline of events that fostered the rapid growth of Bioethics is presented.

“Divine” Committee In 1961 Belding Scribner (Seattle, USA) created a machine which efficiently replaced kidneys Thanks to this machine, the method of chronic hemodialesis extended the life of those who suffer from kidney insufficiency Because there were too many people suffering from kidney insufficiency and too little amount of machines available, in Seattle city the first ethical committee was formed to decide who will be given these machines and thus get a chance to live and who will be left to die. The committee was formed Belding Scribner of citizens and only few of them were doctors.

Creation of the Committee To fight against discrimination (first of all against racial and gender discrimination) served as a starting point for doctors to claim that biomedical achievements must not become a reason for a new form of discrimination: who will live and who will die.

Who decides who will live and who will not? On November 9, 1962, the “Life” journal published Shana Alexan- der “They Decide Who will Live and Who Will Not” article of Shana Alexander.

Ethics and Clinical Research by Henry Beecher On June 16, 1966 Henry Beecher from Harvard Medical School published the article “Ethics and Clinical Research” in the British “New Journal of Medicine”. This article concentrated the public attention on the fact that numerous scientific experimentations were taking place without the patients’ agreement, without sound scientific justification and without getting permission from patients.

1968 - The Harvard criterion of Brain Death The criterion was developed by the committee created by G. Bee- cher. The committee included both: doctors and lawyers, theologists and philosophers. The experience of the “Divine Committee” was used. After Beecher’s article it was clear that the problem is not that physicians and scientists have hateful ideas or hearts.

Christian Bernard case On December 3, 1967, Christian Bernard, a South African cardiologist surgeon transplanted a heart from one person to another for the first time in the world. He saved the life of an incurably ill patient by trans- planting the beating heart of a woman, whose brain was terminally damaged because of a car accident. This event put a start to a very emotional and intense debate. On one side Bernard was called to be a hero, because he saved thousands of incurably ill people. On the other hand, he was proclaimed to be mur- derer, because “How can a beating heart be taken out of the body?” In 1969 the USA was the first country where Den Callahan and Will Gayling created the first educational Bioethical research center (The Hastings Center). In 1970 Andre Hellegers created the “Kennedy Institute for Bioeth- ics” which started to teach bioethics as an independent subject, which was included in the curriculum. From 1974-1978 the “National Commission for Protection of Hu- man Subjects of Biomedical and Behavioral Research” started to function. In addition to these happenings a range of other movements supported the process of formation of Bioethics. These movements include: • The movement of legal protection of embryo and women’s reproductive functions • The movement of protection of patient rights • The movement of humanistic attitude towards animals • The movement of protection of rights of sexual minorities In 1985 Bioethics was included in the activities of European Coun- cil. That is EC undertook the responsibility to ensure the balance between development of scientific progress and human values.

V. R. Potter is a cornerstone figure for Bioethics. His book, “Bio- ethics: Bridge to the Future”, which was published in 1971, became a birth certificate for this new discipline. He regarded Bioethics a new discipline, a unique bridge between biology and ethics, between natural and technical sciences on the one hand and humanitarian studies on the other. He created Bioethics, a science of life which must not be simply a science; it must be a new wisdom which would connect the important and necessary elements of knowledge: the biological knowledge and values of the entire humanity to ensure a life of dignity for the humankind. During the past 5 decades, Bioethics has grown dynamically (77). Today bioethics is an interdisciplinary sphere of knowledge, an academic discipline and a social institution which came to respond to anthropological and ethical problems, caused by intensive development of biomedical sciences and technology.

Specific Characteristics of Biomedical Approach The evaluation and decision on bioethical situations cannot be based only on biomedical expertise. Biomedical experts must cooperate Van Ranseller with specialists of human studies. Biologists Potter and doctors must cooperate with specialists of various human disciplines (Law, specialists of ethics, theologists, philosophers, politicians etc.). There is no philosophical, moral or religious doctrine that would provide a universally accepted set of values or anthropological ideas that would solve problems that grow daily. Bioethical claims are situational. Any Bioethical decision should be made on basis of analysis of the specific situation. Bioethical approach to solving issues of medical ethics can be briefly presented through a range of ethical-legal principles which will be elaborated in later chapters of this handbook. These principles include the voluntary informed consent, justice, confidentiality, respect of personal life, respect of human dignity, respect of personal autonomy etc.

All these principles are well institutionalized and legalized in numerous countries. There are a few major methods of institutionalization for Bi- oethical principles. These include, but are not limited to: • Bioethical Committees – These committees have huge influence in many Western countries. These institutions, sometimes called Institutional Review Boards, may prohibit the realization or publication of any research project they think are unethical for one reason or the other. • Decentralization of responsibility – Bioethics is taught in many countries. As a result more and more people are informed of patient rights. As a result, the paternalistic relationship (presented below) is dissolving and a new shared responsibility model of doctor-patient relationship is institutionalized in many societies thanks to education. • Law – in many countries, many bioethical principles are already legalized. For instance, in many countries there are legal regulations concerning the principle of confidentiality.

What are the main discussions within contemporary bioethics? Contemporary Bioethics discusses questions regarding: • human cloning • organ transplantation • abortion of human embryos • euthanasia • doctor-patient relationships • medical secrets • patient’s rights etc.

Each of these points is broken into smaller, yet very important, sub questions which will be discussed in later chapters. Bioethics is a very practical discipline and it does not manipulate with theoretical concepts like theoretical Ethics, but analyzes real life issues. To solve real life issues Bioethics consults law, sociology, psychology, medicine, philosophy, theology as well as economics and politics. In the following chapters, it will be indicated, why such a wide range of disciplines are necessary for ensuring correct solution of Bio- ethical problems.

Why study Bioethics? The aim of Bioethics is to help people solve real life problems related to clinical settings. The key question here is whether an individual can be taught to solve clinical problems. Evidently, no two ethical dilemmas are the same, thus the individual must always exert creativity, must be able to deal with ambiguity. In this aspect, the solution of a moral dilemma in a clinical setting is like an art. On the other hand, no matter how diverse the real life situations are, they have similarities, and once these similarities are examined and regularities discovered, it will provide a general outline of possible problems and supply with a preliminary strategy for problem solving (78). Thus, Bioethics is both an art and a science as is medicine in general. Often times, people tend to overlook the scientific aspect of Bioeth- ics, considering it simply a set of opinions, let it be even of famous people. However, as further chapters of this manual will demonstrate this is a decisive mistake. In further chapters, it will be made clear, that Bioethics, as a result of being penetrated by psychology and other purely humanitarian studies, serves as a practical guide to curing the person, and not the disease.

Core bioethical values Bioethics, a morality oriented discipline is based on some core values. These values are as follows: autonomy, compassion and competence. Throughout this book, we will elaborate each of these concepts, here though, we will provide a very general description of each.

Autonomy Autonomy is the individual’s capacity to make independent decisions and to act according to personal decisions. The right to autonomy is given, of course, both to the patient and the physician. In certain situations, though, there is the obvious need to limit an individual’s autonomy. For example, a mentally ill patient who acts violently in a public setting is deprived of his right to autonomy and may be hospitalized involuntarily. The deprivation of someone’s autonomy is a central issue for bioethics and is widely discussed in many countries. A more detailed discussion of involuntary hospitalization is provided below.

Compassion Compassion is the ability to feel and share someone else’s pain as one’s own. It is generally believed, that a doctor cannot be a “good” doctor if he/she is aloof and acts as an “engineer” who fixes certain problems that a “mechanism” (i.e. the patient) has. Psychological and medical research proves that the patients overcome their diseases, when they are treated as humans, and not as a body that has some biological problems. Patients, along with professional consulting and purely medical treatment, seek personal connection with their physicians, and once doctors lack personal attitude, they diminish their potential to help.

Competence Doctors, more than any other professional, need to be competent in whatever they do. In order to be competent doctors pass through an intensive and long training program. Today, however, when the science is growing rapidly and when there are thousands of medical articles being published daily, even the best university education is not enough, doctors, need to continually update their knowledge and learn the newest achievements of his/her colleagues to stay competitive. In almost any country, when the doctor is not competent and makes mistakes when treating patients, he/she may lose his/her job or even be sued for negli- gence. Traditional Medical Ethics involves the application of religious principles to patient care. Nowadays, however, most countries are mul- ticultural and secular, and in many countries the sense of objective morality has almost disappeared. This has led to confusion among physicians, patients, and public alike. Universal agreement on moral issues between physicians and patients is no longer possible in our pluralistic society. We now speak of Biomedical Ethics, or the common term Bioethics, as the application of our ethical and moral principles to human life issues. Western medicine was founded on our Judeo-Christian and Greco- Roman heritage, where the sanctity of life and the dignity of the human person are paramount for decision-making in patient care. Autonomy The term autonomy must be understood in two senses: autonomy of doctors and autonomy of patients.

Autonomy of doctors: In past, the number of doctors was much smaller as compared with today. General public did not know much about medicine. Many doctors of the past have been viewed as a kind of witches. Yet many others were royal servants, who helped, obviously only the rich. Because there were no many doctors and no mass literacy and general access to the wisdom of the time, medicine was taught only by doctors to their apprentice, which usually were not many. As a result, doctors of the past had a huge amount of autonomy in making decisions and practicing their knowledge. With the advent of modern age, the number of doctors, as well as of highly educated non-doctors grew. Patients now have the capacity to compare many doctors and to choose the best among them. Because thousands of popular medicine books are available, medicine is not viewed as a mysterious practice and doctors are often challenged by their patients. There are many medical associations, which though at first were found to support doctors, by helping them exchange ideas, now set standards of medical treatment and thus limit the actions a doctor can take at a given situation.

Patient’s autonomy In ancient times, patients had no autonomy in the doctor-patient relationship. But at present, patients feel, they should have the right to choose the method of their treatment. The chapter on patient rights will explain more what are the rights and freedom that at present is commonly given to patients and in which cases can these freedoms be taken away. The autonomous patients are views as the first defenders of their interests and their health, however, it is the general concern of health managers to protect patient autonomy and yet not to impinge on doctor autonomy which is also vital for good medical care.

Exercises and review questions • Who was the founder of the first Bioethics Institution? • When did YSMU start to teach Bioethics? • Think of situations, where a doctor would need ethical knowledge in addition to medical knowledge. • Think about, the contemporary issues of Bioethics. Have you heard of them in the past? Write a very short description of each in your notebook, without consulting any references.

SECTION 5

THEORETICAL FOUNDATIONS AND HISTORICAL STAGES OF DEVELOPMENT OF BIOETHICS

*** After completing this chapter you should be able to: • present key ethical ideas of Socrates, • present key ethical ideas of Plato, • understand the essence of Aristotle’s “Golden Middle” principle, • present ideas of few Armenian thinkers regarding Bioethics, • understand the “Categorical Imperative” suggested by Imman- uel Kant, • understand the principle of “Bowing in front of Life” suggested by Albert Schweitzer.

Ethics and Bioethics Bioethics is based on Ethics. Any bioethical decision is explained or rejected by some Ethical concepts. When someone says that there are laws of nature and claims that it is a law that all heavy objects fall, and then it is “easy” to prove that objects do really fall. One simply needs to drop a few heavy objects and that is usually enough evidence. What about moral laws? Obviously, it is impossible to find a specific enough a moral law, that everyone does really obey to. For example, although it might be easy to think a society where everyone would principally agree that everyone must be honest, it is hard to even imag- 39 ine a society where everyone is really honest. Moral laws are very different from physical laws in this respect. How justified it is to claim that these are laws, when people can not obey to it if they choose so? One of the answers to this is simply to claim that there are moral principles that people should follow to for being “good”, “moral” etc., rather than principles that they cannot diso- bey. The issue then, is which should be the norms that humans must obey? How can they be discovered? What are the bases of moral norms? How do we know what is good? There are many different answers to these simple questions. Below we will present some ideas from a few major thinkers.

Socrates Socrates (469-399 BC) is probably one of the greatest thinkers who has ever lived on this globe. He is known through his student, Plato, who made Socrates one of the heroes of his famous dialogues. Socrates is the founder of ethics in Ancient world. He was one of the first people who examined the human behavior, trying to decide who a person should behave in a given situation. Socrates thought that humans are essentially good, and if someone makes a wrong or immoral dead, the cause for this is the lack of ethical knowledge. According to Socrates, it is the virtue that brings well being and prosperity, and not vice versa. Thus, a person should first of all take care of the soul and not the body. The human body, according to him, is the soul’s servant a tool for it. The main ethical principle for Socrates is the union of knowledge and morality. He thought, that morality is subject to fundamental examination. Human behavior should be natural and well thought. And although, human emotions often take over human reason, the human reason is capable of controlling and restraining human will, his passions and instincts. One might think, that Avetik Isahakyan’s following words come to complete this idea: Life is like a shadow of a cloud that slips away, The only reality is the instant And though the willpower sculptures destiny, The accident is the master of life. The emotions are the master And the mind its simple servant 40

But you be alert, keep your mind awake, As an iron shield, as a strong guard. Socrates thus claims, that morality of a person is revealed from the extant that a man can control his natural condition, aspirations and instincts (49).

What is the supreme good? Socrates thought that the supreme good is the common purpose of all people. He claimed that individuals should subject their private interests and purposes to this common purpose, the supreme good. His personal strategy comes to prove that he lived what he preached. We know from Plato’s dialogues that Socrates thought that the best life is the life which was analyzed critically. A life that is not analyzed does not worth living. He was one of the first people to question the validity of Ancient Greet mythology, and as a result, he was soon convicted to death being suspected in demoralizing the youth and leading them towards open mindedness (What a crime! To lead the youth toward open mindedness!). Allegedly, he had the chance to run away from the prison and be saved, however he preferred to voluntarily drink the poison and die. When the judges informed him, that he was convicted to death by the court, he responded “And you are convicted to death by the nature.” His example shows, that preaching about virtues is not enough for moral restoration of society (33). Plato (427-347 BC) in his moral teaching claimed, that only the life inspired with majestic ideas and full of activities can support the establishment of virtue in society. Virtue is the harmony of order and spirit. According to Plato a virtuous man must be wise, courageous, rightful and be able to control himself. Like Socrates, his teacher, Plato believed that the supreme moral duty is to take care of the soul, that is to clean it. This is possible by abstaining from worldly, bodily life and concentrating on the spiritual. This, however, does not mean living with a life of a hermit, it rather means, dedicating oneself to knowledge. Thus, according to Plato, knowledge is not purely a rational think or a process, but a means for ethical self-improvement, and it can help the person to aspire to wisdom, which itself, is a virtue. By the way, in his “About Doctors” work, Hippocrates claims that doctors must be rightful, because in all forms of activities and especial- 41 ly in medical practice, rightfulness is necessary. The principle of rightfulness is acknowledge to be important both in global-human sense and in medical practice. Aristotle (384-322 BC) was Plato’s student and Alexander the Great’s teacher. His father (Nicomach) was a doctor and when Aristo- tle was an established thinker, he wrote a famous book the “Nicomachean Ethics” which simply means the Behavior of Nichomach. Aristotle also wrote the “Big Ethics” and “Ethics”. These three books gave birth to a new discipline, which is today known as Ethics. Ethics is practical philosophy. It is essentially opposed to the theoretical knowledge about the world. Any theoretical knowledge may eventually have a practical significance. According to Aristotle, Ethics is unique in the sense, that it equips the person with methods and techniques to affect on the environment and people around us. Influencing on others becomes possible when they comprehend ideals of duty, good and evil. By the way, no surprise that the term Deontology is originat- ing from the Greek word deontos, which means mandatory. Deontolo- gy is a discipline about the mandatory, about the duty, about the obligatory. Ethics itself is a discipline about the calling of human being, about the meaning of life, about ethical principles and norms of conduct. Socrates had an unlimited faith in human reasoning and from this standpoint, he made the human passions weak or neglected them. He thought, that if a human being understood something, he would behave correctly. Aristotle, on the other hand, left room for human passions as well and did not exaggerate the role of rationality in human life. He thought, that understanding what is morality is not always followed by the desire to behave morally. To behave morally, one needs moral stability, moral principality and so called emotional-will driven convictions. Aristotle thought, that the true good, is the good revealed in human actions and deeds. This point of view led to differentiation of theoretical and practical issues of ethics. For example, in a given situation, how should a person behave, what steps and actions should he make. No doubt, many issues emerge during curing of patients and the doctor’s greatness depends upon the ability to solve them as effectively as possible. We should not forget that Aristotle himself, as all ancient 42 philosophers, was a doctor. Analyzing ethical concepts Aristotle speaks of the principle of Golden Mean. Aristotle analyzes characteristics as modesty, wisdom, common sense, shrewdness, correctness, humor etc. He claims, for example, that common sense is the middle of hedonism and senselessness. The well-temperedness is the middle of angriness and emotional numbness. Gen- erosity is the middle between wastefulness and stinginess. Honesty is the middle of boastfulness and slave minded obedience. Hardly anyone today will deny the importance of Aristotle’s above- mentioned analytical estimates for discovering the human individual and his moral nature. We absolutely agree with Aristo- tle’s claim, that “although morality depends upon knowledge, it is rooted in good will”. It is one thing to know “What is good” and “What is bad” and a different thing to aspire to do good deeds (49). Gregor Tatevatsi This gets a unique meaning in medi- with his students cal practice. The doctor, more than people of other trade, must be a sample of a humanist, of a generous and dedicated man. The doctor must be positively different from others not only with education, knowledge, but also by culture of language, appearance, refined gestures and sensitivity. Thus ethical ideas of Socrates, Plato and Aristotle are values which are unique and raise questions which have always troubled humanity. These values will maintain their meaning and significance in the future. The moral issues of doctors mission have been succinctly reflected in the “Oath of Hippocrates”. This oath, was made by graduates of famous school of Asclepiads, which was allegedly founded by Asclepius, the god of medicine. One of the most famous graduates was Hippoc- rates The II Great of Cos, who was born in 460 BC and who allegedly, has lived 104 years. It might be said, that the Oath of Hippocrates is the moral code of people doing medicine. The father of medicine has ordered. “Where there is the love towards people, there is the love towards your art.” 43

Can one imagine a person who is not a humanist, who does not love people and wants to cure people?* Of course not, because curing a person is not a trade, neither an art, but a heavy cross. The phrase “Cure the patient and not the disease”, which forms the axis of today’s medicine is also ascribed to Hippocrates. In an another occasion, Hippocrates has written “Whichever house I enter, I will enter for the benefit of the patient, and will abstain from any prejudice, injustice and harm”. The “Ethics of Medical Practice” of Al-Rukhavi, “Rules of Medi- cine” of Avicenna, have had significant influence on history of medical ethics. Many extracts from these books have become wing-words and were translated to Armenian as well. By the way, it should be mentioned that Armenian medical thought has millenniums long spiritual traditions, which testifies the highly developed medical culture of our glorious ancestors. In manuscripts of Armenian historians and doctors we can find ideas about medical profession and ethics. In the work of V century thinker, Eghishe, there are extracts about the image of a doctor (84). In the “About Doctors who Prescribe Poisonous Substences” chapter of “Book about Necessary Knowledge” of Movses Khorenatsi, it is mentioned that the “medical profession should be chosen by most talented and most experienced people” and the medical science itself is compared to a tree, which has fruits that make the life longer and cure the disease. The issues of medical ethics, deontology, life and death have been addressed by V century outstanding Armenian philosopher David In- vincible (his 1500 anniversary was celebrated by UNESCO in 1981 with great festivities), Mkhitar Heratsi (XII century) Amirdovlat Amasiatsi (XV century) and Mkhitar Sebastatsi (XVI-XVII). A. Amasiatsi stressed the importance of following principles of medical ethics in the “Angetats Anpet” published in 1482 in Constantinople. What characteristics should a doctor have according to A. Amasiatsi? He should be smart, full of sense of duty, obedient, able to consult and advise, love the poor, be merciful, loyal, warship God and be immaculate. A. Amasiatsi, also tells, what characteristics the doctor should not have. He should not be an alcoholic and greedy. It should be mentioned that violations of medical code has also been addressed in Medieval Armenia. There have been defined punishments

44 not only for purposeful and accidental medical damage, but also for damage caused because of ignorance (5). In this context the influence of Buddhism on development of medical ethics should be articulated. The founder of Buddhist was Sidharta Gautama, who was also known as Buddha Shakya-Muni (522-543 BC). The doctrine that she preached was based on four virtues and the most important among them is love. One of the best presenters of Siddhar- tha’s life and activities was Herman Hessee, a German writer and we recommend you to read his famous novel “Siddhartha” (32). Buddha has formulated a principle, which is very important for medical ethics: “Brothers, you have no father, no mother and no one takes care of you. If you do not take care of each other, then who will do it instead of you? Brothers, he who warships me, let him warship the patient”. These words are, obviously, about mercifulness towards the patient and about internal readiness to help the patient. These Buddhist norms have been valued by first Christian communities as well. According to the tradition, young Jesus has been a student for “Therapists” who had well studied older medical manuscripts and who had been trying to free people from bodily and spiritual pains. Ancient ideas of medicine as well as Christian religious and moral values started the first medical schools in Europe of XI-XII centuries and medical departments were created in universities. Parallel to the development of medical education and practice the ethics and legal thought were developed. The first manuals of medical ethics were written, the bases of medical law were created in different European countries. Hume is probably one of the most influential philosophers who have written in English. He is known as an epistemologist, that is a person who investigates human understanding, however he has works on history and ethics as well. In ethics Hume questions the objectivity of ethical norms. Are moral norms objective? Do they exist independent of human beings? This is a question that Hume tries to answer. Another question that Hume tries to answer is, how do we understand what is moral or what action should we do? According to him, people can use their reason to formulate different options of behavior. For example, if someone pushes Samvel, Samvel can think rationally and de- 45 cide that he has, say, three options, a) push back, b) smack the person c) ask for explanation. But which of these actions will be chosen by Samvel, does not depend on reason, but on the moral capacity of the person. Thus, according to Hume, the good will of the person is the essence of human morality. Hume claims that “The nature has en- dowed us with the capacity to be empathetic towards others. With this capacity the nature has given humans the duty to share another person’s happiness and suffering as our own. We should feel another person’s pain, as our own.” Immanuel Kant is a representative of German Enlightenment. He started his academic career as a physicist. Later though, he became one of the most influential thinkers of humankind. He has written a few books, the most important one in this context is, probably, “The Critique of Practi- cal Reason”. In this book, as well as in his mas- terpiece “The Critique of Pure Reason”, Kant develops the idea of Categorical Imperative. Categorical Imperative is a moral principle that is I. Kant necessary for all individual in all circumstances. It requires that humans behave in a way that can be a universal norm. That is, one should behave in a way, so that if everyone else behaved the same way, the world became a better place. Kant also speaks about two very important concepts: purpose and means. According to Kant, we should always treat other people as a purpose and never as a means. Kant claimed that human conscience tells what is good and what is bad. We should listen only to our conscience. Kant believed, that one of the most important anthropological principles is that “Humans aspire to create a law for themselves” and to fight for this law without any external imposition. Kant calls this characteristic “ethical autonomy”. Kant writes “Ethical autonomy is the bases of dignity for humans and for other rational beings.” Jeremy Bentham, an English philosopher and lawyer wrote his famous “Deontology or about Morality” in 1834. In this book he claimed that deontology should be based on usefulness, utility. Thus, he believed that an action can be considered good or bad, worthy or worth- less based on the fact that it adds or decreases the social, common good 46 and wellbeing. This approach, was known as utilitarism. Which as we saw is incompatible with D. Humes emotivist approach according to which we should be empathetic towards other peoples’ happiness and pain. And truly, isn’t it the time for all of us to understand and comprehend, that the Earth and people who live on it, disregarded of their religion, faith, political, sexual and other belonging, are one body and when one part of the body, one cell is ill, then the other part or the whole body can never be healthy. Thus, when in one part of the planet (be that part a country, area, city etc.) a misfortune is taking place, a war emerges, a disaster then we should not think, that it does not have anything to do with us. Each of us must be convinced that we are a whole and therefore, we can either get healthy together and move on, or get ill and stick to our place. The following is a good example of what was said. On March 4, 1897 the people of Switzerland, a country that has adopted the principle of neutrality, presented to the government of Switzerland a request of half million citizens of Switzerland to criticize the Armenian massacres in Western Armenia which happened in 1895-1896. This truly proves, that a righteous nation cannot feel fully happy and have the sense of integrity, when the others nearby are in a misfortune (8). Hundred years later, the Armenian community in Switzerland presented to the Government of Switzerland a note of appreciation for the fact that on March 4, 1897, the people of Switzerland had expressed their voice of condemnation of massacres of Armenians and the anti- Armenian policy that the Turkish state had adopted. Above, the issue of what is a virtue was considered. Yes, doing good, being responsible, as well as being grateful are also virtues, forms of exemplary behavior. Albert Schweitzer (1875-1965) is outstanding not only with his ideas but also with his exceptionally morality driven life. He studied in the universities of Strasburg, Berlin and Paris. In 1899 he earned his PhD in Philosophy (“Kant’s Philosophy of Religion”) and later, in 1906 he decided to study medicine with the aim of traveling to Africa to help the local population. In 1913 he earned his MD degree. In 1913 he left for Africa, although many of his friends and family members were against this decision. He moved to Lamberene (Gabon) where he created a hospital and worked till the end of his life. 47

All his life he supported the local people in Africa, educated them, and raised millions and millions from Europe to improve health condition in Gabon. In 1932 he was given a Goethe Award, in 1952 he was awarded a Nobel Prize for peace. In the center of his ethics is the suffering individual and its destiny. Schweitzer was influenced by Kant, Goe- the, late Stoicism, Lao-Tsi and Christianity. He has demonstrated that the ethical values of modern society are distracted and that a person is in bondage. The individual is free, and one of the reasons for it is the Hegelian formula for rational reality. Struggling against Hegel, and his panlogism, Schweitzer approaches to existentialist views of Syoren Kierkegaard in which the central role has the person who lives with suffering, with a meaningless Albert Schweitzer life, deprived of ethical bases. Driven with the same existentialist spirit, he suggests two principles: the will as an expression of free and moral creature and the knowledge, the bases of which is the capacity to force to obey to the external necessity. When the world is viewed by a human being, it leads the individual to skepticism, a deep disbelief towards reason. Schweitzer called to free ourselves from the slavery of the reason and to rely on active en responsible attitude towards life. “We should not deduce our views about life from our knowledge of the world. My knowledge has pes- simistic nature, but my will has an optimistic nature” (53). The primary fact for Schweitzer’s world view is the life itself, which is put in opposition to the fact of mind. The mind is based on life. “I am the life, who wants to live in the life, which wants to live.” And from this point he deduces the principle of bowing in front of life. “The desire to protect all forms of life must become the bases for moral renovation of humanity.” He believed in God, which has gained its most majestic revelation in the appearance of Jesus Christ. Schweitzer suggests to replace rationalism with new “magic” world- view with the sanctified faith of warm life. He calls for bowing in front 48 of life and protecting the humanity “by personal deeds and concrete activities”. Schweitzer is convinced that the fact of existence, of life goes before the fact of consciousness and thinking. The great humanist clearly defines what is good and what is bad. “The good is that which serves the protection and development of life, the evil is that which de- stroys the life or hinders it.” “Each mans existence is tightly related to other people and thus a man cannot be foreign to others. Each man should think about the others and ask: “Do I have the right to pick the fruit that I can reach for?” (53). We need not only think of others, but mind their interests. This is the meaning of Schweitzer’s call for humanity. The purpose of active morality is to improve the world. Schweitzer argues with Kant and criticizes the concept of doubt protecting the concept of moral freedom. He believed, that in every given case, we ourselves must decide to what extent we are able or are willing to be moral, and to what extent must we obey to the necessity of causing harm.” According to Schweit- zer, morality is the unlimited responsibility towards everything that exists. Schweitzer loved to repeat that a man can be saved by the faith, hope and love and often quoted the following phrase from the New Testament. “And if I had a grace of prophecy, and if I had all wisdom and knowledge, and if I had all the faith enough to move mountains, but I had no love, I would be nothing.” The ideas of the great humanist sound very urgent even today, because in the center of these ideas are human suffering and destiny.

Following notes from Alisa Kirakosyan confirm these words. Love is the only genius of existence The opposite of loving is not the disliking, It is the death Those in love renovate the eternity.

Exercises and review questions: • What is ethical deontology? Who is the author of this theory? • Compare moral deontology with the Golden Rule of Bible. Which is better? • Study the 5 universal principles elaborated by the other groups. Think of situations, where these principles are not applicable. 49

• What is competence? • What is autonomy? • What are the two meanings of the term justice • Think of other principles that you think should be included here as basic principles of bioethics. Prepare to justify your claim.

SECTION 6

HISTORICAL MODELS OF BIOETHICS AND TYPES OF DOCTOR-PATIENT RELATIONSHIPS

*** After completing this chapter you should be able to: • understand Talcott Parsons’s functionalistic theory of doctor patient relationship, • name four main types of doctor-patient relationship, • name the weaknesses and strengths of each type of relationship, • identify these types of personal relationships in real social settings. Historical Models of Bioethics Medical ethics is believed to be founded by Hippocrates, the father of medicine. Thus, medical ethics is as old as medicine itself. Hippocrates’s code of ethics is well presented in his famous oath, which is presented in the section of documents on bioethics. Hippocrates was an extraordinary medical writer of Greece. Little is known of his life beyond the fact that he was a physician on the island of Cos. He lived during the most intellectual period of Grecian life, and that Hippocrates was Hippocrates singularly free from superstition. Over eighty treatises have been attributed to him, but it now is conceded that some were written by others who borrowed his name and 51 reputation. His works form ten volumes, an encyclopedia of medicine and surgery. Hippocrates is the father of scientific medicine. He did not believe in miraculous diseases or cures. He taught that proper diet is a necessity of health, and that climate has a profound influence on both mind and body. He died in Thessaly. Do Not Harm ( in Latin) It might seem, from the first glance that the principles “Do not harm” and “Do Good” are the same. This, however, is not true. A doctor may not do good, and yet not harm as well, but he/she may not do good, and harm the patient instead. Patients approach the doctor with great expectations. They have severe pains and they want to get rid of these pains. So they look up at the doctor as a “source of hope”. Hurting these people instead of relieving their pain, can serve as a reason for mistrust among many and many patients. As a result, patients go to doctor only when their disease has escalated to a dangerous stage and when it is much harder to help. Beneficence - Do good (Sac Bonum (in Latin)) Beneficence principle is the principle of “wishing good to patients”. The principle sounds like this in English: “Do Good”. Some questions with this principle are: “What is good for patients?”, “Who should decide what is good for patients?”, and finally “What are the limits of doctor’s self sacrifice for doing good to patients?” The “Do Good” principle is central for establishing trust between the doctor and the patient and is viewed as one of the fundamental ethical values that doctors around the world should have. Deontology Justice Like the term autonomy, the term justice has two interpretations: justice is equal access to medical service and equal satisfaction of medical needs. Equal access to medical service Because medical service is a basic need for anyone, it has been claimed, that everyone should have access to medical service. In all times of history, however, medical services have been either scarce or too expensive for a large portion of the population. At present age some claim that governments should fight this unwanted situation. One of the methods was to share all available medical

52 resources evenly among population. This creates many further questions for a range of reasons: a) in most cases, people do not need these resources: What will a healthy 10 year old child do with insulin? b) When distributed evenly, the resources can become useless for everyone: a diabetic needs a minimum amount of insulin; if it is less than the minimum prescribed the results will be unsatisfactory Equal satisfaction of medical needs This approach seems to solve the problem of mechanical equality; however, it creates other problems: a) who will decide what the needs are? And more importantly, who will decide how medical needs are equally satisfied. Of course in real social settings, these two principles, as well as other moral cultural convictions (priority to children, women, elderly etc.) are taken under consideration.

Types of Doctor-Patient Relationships The study of doctor-patient relationships is believed to be central in medical care for a range of reasons: a) Doctors and patients need to be able to communicate effectively. In cases when the doctor or the patient is irritated, feels neglected or unappreciated poor communication can take place, which eventually can lead to poor diagnosis or delayed diagnosis of diseases. b) Recent research has demonstrated that patients generally recover one or two days earlier, when they feel personally loved rather than, when they get a professional treatment from a cold blooded and emotionally neutral doctor.

The functionalistic theory of doctor-patient relationship Talcott Parsons was the first social scientist to theorize the doctor- patient relationship, and his functionalistic, role-based approach defined analysis of the doctor-patient relationship for the next two decades. Par- sons began with the assumption that illness was a form of dysfunctional deviance that required reintegration with the social organism. Illness, or feigned illness, exempted people from work and other responsibilities, and thus was potentially detrimental to the social order if uncontrolled. Maintaining the social order required the development of a legitimized "sick role" to control this deviance, and make illness a transitional state

53 back to normal role performance. Parsons saw four norms governing the sick role: 1. the individual is not responsible for their illness; 2. exemption of the sick from normal obligations until they are well; 3. illness is undesirable; and 4. The ill should seek professional help.

Sociologist and educator, born in Colorado Springs, Colorado, USA. Educated at Am- herst College, the London School of Eco- nomics, and the University of Heidelberg, he spent his long academic career at Harvard (1927–73), where he founded the department of social relations (1946) and trained three generations of students. His first book, The Structure of Social Action (1937), launched a lifelong effort to supplant traditional em- pirical sociology with a theoretical approach that synthesized existing theories from all the Talcott Parsons social sciences. Parsons had a huge influence on social thought of the 20th century. For Parsons, the physician's role is to represent and communicate these norms to the patient to control their deviance. Medical education and social role expectations require physicians to act in the interests of the patient rather than their own material interests, and to be guided by an egalitarian universalism rather than a personalized particularism. However, the truth is that physicians often react negatively to dying patients, patients they do not like, and patients they believe are com- plainers. Physicians are sometimes driven by personal and financial interests. It has been demonstrated that different types of relationships are formed between doctor and patient in case of different illnesses. Pa- tients are passive and physician assertive in case of acute illnesses; in case of less acute illnesses physicians are guiding and patients are co- operating. In case of chronic illness, doctor patient relationship is char-

54 acterized by physicians participating in a treatment plan where patients have the bulk of the responsibility to help themselves.

Classification of doctor-patient relationships There is a general tendency to classify the vast variety of doctor-patient relationships into four groups: paternalistic, technical, contract based and bioethical.

Paternalistic relationship The word "paternalistic" means of/characteristic to father. When this type of relationship is functional, the doctor treats the patient as a child and thus undertakes full responsibility for curing the patient. In this case the doctor makes all decisions, and the patient is expected to be absolutely obedient and thus looses his/her autonomy. This relationship helps parties to build tight interpersonal relationships, when the doctor is much respected. This form of doctor-patient relationship seems to be in the process of deinstitutionalization in the West. There are a few reasons for this. This type of relationship was dominant when: • Family doctors did most of the work. • there was no progressive specialization of doctors • general public was uneducated about human anatomy and general medical practices • doctors were very scarce

As time progresses all four of these characteristics change: family doctors disappear and specialized doctors emerge instead, the narrow specialization of doctors gets even more sophisticated, general public gets more and more educated about medical issues, the number of doctors continues to grow throughout the world.

Technical The name technical characterizes this type of doctor-patient relationship. When this type of relationship is functional, the parties are dehumanized, the doctor is viewed as a type of a mechanic and the patient is viewed as a broken machine, which needs to be fixed. In case of this relationship, the doctor again takes the most share of responsibility, however unlike in case of paternalistic relationship; there is no tight 55 interpersonal emotional tie between the two parties, but rather a grocer- customer type of relationship. In case of technical relationship the doctor gets a lot of trust as in case of paternalistic relationship.

Contract based This relationship is an extreme form of grocer-customer attitude between the doctor and the patient. In case of this relationship, the patient is viewed as a client, who will pay some amount of money for a specific service, a treatment. It is generally held by patients, that doctors are a type of grocers, who sell a specific type of service: medical service. When viewed like this, it is very easy to find reasons of mistrust, thus in many western countries, it has become a common practice to sign an oral and sometimes a written contract between two parties. The contract has three aspects, what medical service will the patient receive? (What will the results of the treatment be?) How much money will the doctor get? And what are the responsibilities of parties? In this case, there is a low level of trust, high level of both doctor and patient autonomy, low level of interpersonal emotional connection and even share of responsibilities (81).

Bioethical attitude towards doctor-patient relationship The bioethical attitude towards doctor-patient relationship aims at establishing relationships where: • both parties are autonomous • both parties are respected • there is an acceptable level of interpersonal emotional connection • the relationship is built on mutual trust and reasonable distribu- tion of doctor-patient relationships These types of relationships, at present, do not exist in clean forms. Real doctor patient relationships are mixes of these, however, according to sociologists the bioethical model of doctor-patient relationships will grow more and more popular during time. The types of doctor-patient relationships are differentiated first of all by subjective interpretation. When situation is interpreted in a particular way, people tend to act in a slightly different way in specific situations. Throughout this book, the readers will discover more about the bioethical approach of doctor-patient relationships. 56

Exercises and review questions • Convey a brief research and prepare a paper on feminist approaches to doctor-patient relationship. What aspects of relationship do they concentrate on the most? • Research the Medical Code and ground level practices in medicine in your country. What type of doctor-patient relationship is dominant in your country? Why? • What is technical type of doctor patient relationship? • What are the elements of bioethical relationship between doctor and patient?

SECTION 7

DOCTOR’S DUTIES AND PATIENT‘S RIGHTS

*** After completing this chapter your will be able to: • define the concept of medical secret • explain two meanings of the term “Medical Secret” • Understand arguments for and against revealing secrets in case of undesirable diagnosis. • understand arguments for and against revealing secrets in case of dangerous diseases

The term medical secret is an old one. Starting from Hippocrates, a tradition has evolved, which has prohibited doctors to spread information about their patients, even after their death. The imperative of the medical secret has two aspects: 1. the patient has a right to be fully informed of his/her medical situation, that is, to know everything that the doctor knows about him/her 2. The patient has a right to privacy, that is, the doctor, does not have a right to reveal the information about the patient to any third party.

The first meaning of the term, gives basis for one of the major patient rights: the right to informed consent. How justified is this rule, and what is its scope? 58

As, in the framework of contemporary medicine, patients are responsible for their health as much as doctors, and maybe even more, then they need to know what is happening to them. From the first sight, it causes no problems, however it does in two aspects: a. undesirable diagnosis, b. disclosure of medical mistakes

Undesirable diagnosis Often times, doctors face the situation, when a patient, full of optimism, is waiting for the magic prescription so that they can celebrate a complete victory over disease, however, the doctor, after ordering certain tests, is more than convinced that the patient has little to celebrate. What should the doctor do in such a situation? Should he/she simply say: “Sorry, but you’d better say good-bye to your family? Or, should he/she encourage the patient’s optimism. Very often doctors share this information with family members. But this solution is definitely a debatable one. Would the patient be willing to tell his/her family himself that he is dying? Would the patient be willing to hide that information from a particular family member? Would the patient be willing to prepare himself/herself to death? We suggest read or that students attend and discuss the “Physiology of the Tribe” by Aghasi Ayvazyan staged in the theatre of H. Malyan. This performance presents an aged doctor who gets “life” and “spirit” only when he is useful to someone. Apparently Aghasi Ayvazyan has used art to express the very idea that Plato has articulated long ago: Do not heal the body unless you heal the spirit (6). On the other side, some people argue, Aghasi Ayvazyan that it is better to hide the undesirable diagnosis from the patient, so that the patient can “enjoy” the last days of his life. Those who argue for disclosing the unwanted diagnosis also suggest a few rules as how to do it.

Disclosure of medical mistakes The phenomenon of medical mistakes raises a broad range of discussion topics, such as: How should the harm be compensated? How to avoid harm? What punishment to define? Obviously, there is a range of reasons why doctors would not want to reveal their mistakes:

The doctor may not even be responsible for the mistake. Con- temporary hospitals are a very elaborate network of people working together. The fault could be the fault of others.

Disclosure of the mistake could harm the patient. Once one mistake is disclosed, the patients will become unnecessarily worried and suspicious about the rest of the treatment.

Disclosure may harm the health care professionals. Patients might get angry, require compensation or even open a lawsuit. Moreo- ver, it may damage the doctor’s reputation as a good physician.

On the other hand, there have been arguments, which claim the opposite: Disclosure respects patient’s autonomy. When the patient knows that he/she has suffered more because of a medical mistake, and when in such a case, the doctor does not tell the truth, the patient may continue to worry about his/her health, he/she may visit other doctors for consultations or limit his/her activities because he/she would guess that some of his/her activities caused the problem.

Disclosure benefits the patient. Telling the truth about the mistake helps the patient to undertake quick actions to prevent the future harms of the mistake. Moreover, the patients become more educated, and hence force doctors to take more cautions for the future. When mistakes are disclosed, patients may even get corresponding compensation for the harm they suffered.

Disclosure benefits health professionals. Disclosure of the mistake helps doctors avoid the need of inventing a bigger lie, moreover, once mistake is disclosed, doctors will have to undertake responsibility for solving the “new” problem.

At present stage of development of medical practice, there are standard medical procedures for almost any medical treatment. Thus a mistake is not only the act that harms the patient, but simply the act, when the doctor does not follow the standard procedures. In this sense, it is possible that: 1. There is a mistake and the mistake has harmed the patient 2. There is a mistake and the mistake did not harm the patient at all.

Doctors as well as patients should also be aware, that in many cases, there is absolutely no mistake; however the medical treatment has a negative outcome for the patient.

Disclosure of medical secret The law or rule on medical secret states, that a doctor should never reveal the information about the patient. This norm is defined to ensure that patients fully trust the doctor and that they do not hide any data that could be used when diagnosing or healing the patient. This norm, however, finds itself in conflict with other widely accepted norms. Sometimes, for example, doctors find out that their patient is a drug addict. Many legal codes, including the one in Armenia, require the doctor to report this kind of finding to police. If a doctor hides this information from the police, he/she may be accused in cooperation with the drug addict and be sued. This however is not the only case. There are occupations, which require a certain health condition, for example, a driver is expected to have a good vision and not to suffer from any mental diseases. In similar cases, the doctors in many countries are encouraged to report to corresponding bodies. In Armenia, for example, any person, who would like to get a driving license, must have the doctor’s expert assessment regarding good health condition. This similar procedure is followed to for getting license for many other occupations. This practice, however, undermines the trust towards medical institutions. As a result, people, who have the fear that will end up in police, or by losing their occupation, are hesitant to get medical treatment at all or are very secretive when dealing with doctors, trying to hide the information that could be used against them. This, however, is seldom very helpful, because in fact, patients, like this, hide useful information from physicians. 61

Exercises and question reviews? • What are the two meanings of the term “medical secret”? • What are some problems of disclosing medical mistakes? • What are some potential benefits of disclosing medical mistakes? • What are the problems, with disclosing medical secrets?

SECTION 8

DOCTOR’s ETIQUETTE

*** After Completing this chapter you should be able to: a. Understand the importance of body language b. Understand the meaning of many body gestures c. Read a few basic body gestures. d. Acquire skills for continually improving your emotional intelligence.

Human communication takes place both verbally and physically, though body language. If we are not aware of the messages we convey through our posture, voice, facial expressions and body movements we will often end of with unsuccessful communication processes. To ensure the highest efficiency of communication, it is important to choose the right things to say, to choose the right words for saying these things and which is very important to use proper body language. An Ameri- can psychologist started to provide trainings to thousands of people, who wanted to improve their communication skills. This psychologist, Dale Carnegie, wrote probably the first book, in which the abilities to influence on others and to make friends are presented as basic kills, not a character, but skills. Below a few very important body language signs are presented with their interpretations. It is generally believed that doctors who can better understand the body language used by his/her patients or who can better “Speak” this language are more successful. Doctors who master the body language signs, which are universal, ensure higher level of patient satisfaction. Moreover, when proper body language is spoken, patients tend to trust their doctors more.

NONVERBAL BEHAVIOR INTERPRETATION

Brisk, erect walk Confidence

Standing with hands on hips Readiness, aggression

Sitting with legs crossed, foot Boredom

Sitting, legs apart Open, relaxed

Arms crossed on chest Defensiveness

Walking with hands in pockets, Dejection

Hand to cheek Evaluation, thinking

Touching, slightly rubbing Rejection, doubt, lying nose

Rubbing the eye Doubt, disbelief

Hands clasped behind back Anger, frustration, appre-

Locked ankles Apprehension

Head resting in hand, eyes Boredom

Rubbing hands Anticipation

Sitting with hands clasped be- Confidence, superiority

Open palm Sincerity, openness, inno-

Pinching bridge of nose, eyes Negative evaluation

Tapping or drumming fingers Impatience

Steepling fingers Authoritative

Patting/fondling hair Lack of self-confidence;

Tilted head Interest

Stroking chin Trying to make a decision

Looking down, face turned Disbelief

Biting nails Insecurity, nervousness

Pulling or tugging at ear Indecision

The proper body language is in fact very different from culture to culture and it is very diverse even within the same country. Body language evolves during time. So speaking the correct body language requires a great deal of observation and imitating others. However, as mentioned in the table above, there are universal body language signs which are fairly unchanging, universal and unambiguous throughout the globe.

Exercises and review questions. a. Turn the sound of the TV off and watch a film. Try to understand emotions of actors. Try to guess the topic of their con- versation. If possible, watch the same film with the sound. b. Search the web and learn more about Dale Carnegie. What other similar thinkers can you find in the web? c. What do tapping or drumming fingers signal? d. Search the web about “Personal space”. What is personal space? What should doctors know about personal space? Pre- pare a few minutes long report on personal space. e. Search the web about “Social Intelligence” What is social intelligence? What should doctors know about social intelligence? Prepare a few minutes long report on social intelligence.

SECTION 9

INVOLUNTARY HOSPITALIZATION AND STERILIZATION OF MENTALLY ILL PEOPLE

*** After completing this chapter you should be able to: • understand what is involuntary hospitalization • explain the purposes of involuntary hospitalization • explain possible risks of involuntary hospitalization • Say some things about forced sterilization.

What it involuntary hospitalization? Involuntary hospitalization is a legal procedure used to compel an individual to receive medical treatment for a mental health disorder against his or her will. The legal justifications are numerous but are generally based on the claim that the person is imminently dangerous to others and to him/her; is gravely disabled; or clearly needs immediate care and treatment. Involuntary hospitalization is synonymous with involuntary commitment or involuntary treatment, and is an extremely controversial course of action. It is generally a last resort used in dealing with a person who is so ill that he/she is unable to use proper judgment or insight in deciding to refuse treatment. 66

What are the purposes of involuntary hospitalization? The governments, no matter of democratic country or not, undertake some responsibilities. Including the responsibility for protecting each citizen from injury by another and to care for a disabled citizen. A person with a significant mental illness may be civilly committed, or involuntarily hospitalized, under either of these powers. It is understood that the purpose of civil commitment is protecting the safety of the public or of the ill person. Before a person can be involuntarily hospitalized, a proof of dan- gerousness of the patient is required. Beyond safety issues, mental health professionals have thought that proper psychiatric treatment, even when administered against a person's wishes, is preferable to the continued worsening of a serious mental illness. There is some question currently about the effectiveness of forced treatment in the legal and mental health communities (62). What potential risks are there for involuntary hospitalization? The use of involuntary hospitalization or Philip Pinel Philip Pinel any other form of forced treatment is perhaps the most controversial issue in the wider mental health community. Legal advocates and the courts take very seriously the denial of a person's liberty. Involuntary hospitalization is one of the most extreme examples of denial of liberty in a democratic society. Most people involved in the debate would agree that forced treatment is indicative of a failed treatment system. There is some evidence that forced treatment is generally harmful and counterproductive. Yet, many people with an intensely personal stake in such a decision may see the necessity of forced treatment to prevent harm to the person with an illness or to others. There is great concern, often based on experience, that a person who has been civilly committed to a treatment fa- cility, will also receive such forced treatment as strong antipsychotic medications or electroconvulsive therapy (ECT).

The issue of a person's ability to exercise informed consent about his/her treatment is clouded when the legal process of civil commitment has been initiated. In addition, there is concern that inpatient treatment will add to the stigma of being diagnosed with a mental illness. On the other hand, there are many mental health consumers who claim that an inci dent of involuntary hospitalization in their own treatment history may not only have saved their lives, but enabled them to receive treatment at a time when they were not capable of making a decision to do so. Family members sometimes consider involuntary hospitalization their only recourse to prevent the down- ward spiral of a loved one into a severe and debilitating mental illness, contact with the criminal justice system, or the devastation and dangers of homelessness. Involuntary hospitalization is a complex Tennessee Williams process because of the legal requirements that have been put in place to protect citizens from being hospitalized because of a family quarrel or similar interpersonal issue. In the past, for example, it was commonplace for husbands who wanted to end a marriage to have wives hospitalized against their will, or for parents to commit "disobedient" children. At present, however, the person will need a medical evaluation, including assessment for substance abuse or withdrawal, before the doctor can proceed with a psychiatric assessment. The psychiatric assessments are thorough, and documented as completely as possible; laboratory tests will be ordered if necessary. When after the assessment is complete, the doctor is legally required to decide in favor of the least restrictive environment to which the patient can be safely discharged for continued care. If the doctor decides that the person is dangerous but not mentally ill, he or she will turn the person over to law enforcement. If the person has threatened to kill him/herself, but the psychiatrist does not consider the threat to be lethal, he or she may allow the patient to leave the emergency room after assessment. A decision to hospitalize the person involuntarily is based on three considerations: loss of emotional con-

68 trol; clear evidence of a psychotic disorder; evidence of impulsivity with serious thoughts, threats, or plans to kill self or others. A number of factors in the early 1980s led to a trend toward declin- ing use of involuntary hospitalization for people with significant mental illne sses. The development and effectiveness of a range of new medications meant that treatment in general was more successful. The continued move toward deinstitutionalization, or moving people out of hospitals and into their communities, contributed as well. Treating people in hospitals is inherently expensive and was being viewed as less effective, compared to more innovative and less costly forms of treatment in smaller community-based programs. Finally, a continuing concern about civil liber- ties led to closer court scrutiny, the right to a hearing and legal counsel, and laws establishing a person's rights to the least restrictive form of treatment. Most persons involved in the mental health community believe that an adequately funded, community-based continuum of care and treatment would drastically reduce the number of cases in which involuntary treatment of any Lukas Barfuss kind is necessary. The use of psychiatric advance directives may have an effect on the use of involuntary treatment as well. A psychiatric advance directive is a clearly written statement of an individual's psychiatric treatment preferences or instructions, somewhat like a living will for medical conditions. Psychiatric advance directives have not yet been tested in the court system but are widely endorsed throughout the mental health community as an alternative to involuntary treatment (62). Similar or somewhat more complicated problems rise with involuntary sterilization of mentally ill people. As in regards to other bioethical issues, the answers are parted into two. Arguments for involuntary sterilization These arguments are usually based on negative beliefs about people with disability and suggest reproduction of impaired people, especially those who were born with disability, weakens the gene pool and reduces competitiveness by using the nation’s wealth and being a burden on

69 the state highlight negative perceptions and low value of the worth attributed to people with disability reinforced by the long established precedent of sterilization over millennia Arguments against involuntary sterilization These arguments reject eugenic beliefs about people with disability emphasize the socio-political nature of the issues especially relating to the sterilization of young women with intellectual disabilities reject beliefs about eternal children and asexuality reflect the changes in attitudes about the rights of people with disability use other girls and young women as the yardstick, that is those without disabilities, where removing the womb and/or ovaries is only used to treat illness or disease.

There are a few social factors that encourage sterilization or maintain the status quo with regard to young people being sterilized. These factors include: Lack of progress about the seriousness of the issue of sterilization Lack of progress has continued, not only socially and politically, but also personally, in terms of the lack of understanding about the gross intrusion and invasiveness that sterilization has on a young person’s body.

Neutral and benign language used to justify procedures The same arguments are used around the best interest of the individual as were used around the best interest of society at the time of the eugenics movement.

Extreme devaluation of people with disability especially girls and young women The whole lack of respect for the humanity of these young people is shown by the devaluing burdensome language attributed to them and by the most restrictive responses as the first option, such as even by considering such unsuitable practices as a hysterectomy or vasectomy for any 10 year old child.

The power and authority vested in the medical profession as social arbitrators The language and discussion are locked in medical discourse allowing medical approaches to be seen as taking the high moral ground or 70 altruistic position, so that their subjective opinion and confidentiality are beyond question with the assumption that their procedures will address the child’s and family’s needs.

Speculative decision making by medical and legal decision mak- ers Decisions to sterilize are often based on unknown projections about the future, so that there is no reasoned argument to work through possible options and alternatives, which is highly dangerous when the re- moval of a body part and its consequences cannot be appealed against or altered by a later more informed decision.

The paradox of expected competency and maturity Young women with intellectual disability are expected to manage menstruation instantly without the usual socialization or opportunities to learn skills over time and are often described as stubborn, difficult and impulsive; terms which could relate quite easily to other teenage girls.

Hysterectomy as the vehicle for achieving quality of life The operation is held up as the means of lifting burdens, enabling community inclusion and being the least restrictive option, which is similar to the eugenics argument that people were free to leave institutions if they were sterilized.

Hysterectomy as the safeguard for group living Fear of workers and other residents’ sexually abusing women with disability has led to the expectation that hysterectomy is a prerequisite for some people going onto group living situations, this being fuelled by the statistics that at least 40% of women are sexually abused in care. Yet sterilization does nothing to protect these people from sexual abuse.

Non-questioning of the illegality of sterilization without authorization The question remains how so many girls and women could be ille- gally sterilized within the private or public hospital system without questions being asked by other specialists, theatre staff, nurses or hospital administrators, and how sterilization could be performed under the guise of a differing medical procedure, when even to the untrained eye the differences between an appendix and a uterus are obvious.

Kirlian Effect One of the most general and most universally used methods in science is so-called perturbation technique*. Response to a well chosen perturbation can reveal object properties that are not obvious when the perturbation is absent. For example, if you need to know if a wall next to you is solid or hollow, all you need to do is to "knock" it gently and listen to its response. The response Kirlian Simion of the wall (the sound it emits) reveals (1898-1978) the wall's internal properties. Similar approach is used to investi- gate properties of extremely wide range of objects in all imaginable scientific disciplines: from physical, biological, Real World objects and systems to objects of purely hypothetical and imaginary nature such as mathematical models (21). Kirlian Effect is a visible electro- photonic glow of an object (see the picture below) in response to pulsed electrical field excitation. The magnitude of the excitation is adjusted to induce the avalanche effect in the gas surrounding the object. The avalanche effect ampli- fies the response of the object so that it can be observed as a visible glow. The effect has been observed

* The following few paragraphs and the photo below are adopted from http://kirlianresearch.com/kirlian_principle.html. 72 by Tesla late in 19th century, but named after Semion Kirlian who investigated it since 1930s. Note, that there is no point exciting object in vacuum, since the avalanche effect amplification of the object response can only occur in ion- ized gas. Much like a sound of a disturbed wall reveals its internal properties, the visible electro-photonic glow contains information about the object that was excited to glow. In early days, Kirlian images were recorded on photographic emulsion. Since the sensitivity of a photographic emulsion varies greatly with environmental factors such as humidity, recordings were not re- producible. As a result, some scientists dismissed the Kirlian effect as useless (21). Kirlian effect is also used in medicine and it provides additional reliable methods for diagnosis. Kirlian effect is particularly useful diagnosing diseases that otherwise cannot be diagnosed. Kirlian effect in fact, serves as a reliable means for diagnosing the disease ahead of time, when other diagnostic means are helpless.

Exercises and review questions

• Prepare a research paper on involuntary hospitalization practices in your country. • Prepare a research paper on involuntary sterilization practices in your country. • What are some factors that maintain the status quo in regard to involuntary sterilization? • What is involuntary hospitalization? • What are the purposes of involuntary hospitalization?

SECTION 10

INFORMED CONSENT

*** After completing this chapter, you should be able to: • define the principle of informed consent • explain the need of practicing informed consent • identify some possible problems of practicing the informed consent

The Lisbon Declaration on Patient Rights (1981) claims that the patient has the right to accept or refuse to accept medical treatment after getting information. According to this claim, the doctor must inform the patient about his/her health situation, about the purposes of medical tests ordered, about the results of diagnostic tests and treatment procedures as well as possible risks of treatment. This declaration, as well as other similar declarations, give rights to patients and limit doctors’ absolute autonomy. The doctor, hence, must try his/her best to: • reveal all possible negative outcomes of medical examination and treatment and yet encourage the patient to cooperate for the desired outcome of the treatment • Get the patients voluntary agreement for conducting examination and more importantly, medical treatment. In many countries, the patients sign a paper, which claims that the patient was informed of possible risks and expected outcomes of medical treatment, however, in many countries this is simply a formal act. The principle is problematic for many doctors because in order to follow this principle the doctor must educate the patient, in addition to simply following to well established medical standards and procedures. Medicine is a branch of knowledge, that requires years of intensive training before one can be considered to be a competent judge in specif- 74 ic situations, yet, very often doctors are forced to obey patients’ preferences, which often times, can be viewed as simply wrong by doctors themselves. The principle of informed consent is vital both for patients, who seek remedy for their pains and for human beings who are subject of medical experimentation. The answers to the following questions are generally sought, before a human being can be subject to experimentation: Is there a threat for the human being? What threat is it? What are the potential benefits of the experimentation? What will be the procedure of the experimentation? Is it a scientifically justified experimentation, procedure?

These points are further elaborated in the section on Human Exper- imentation below.

The practice of informed consent has many positive aspects as well. It simply guarantees that no doctor will limit the patient’s autonomy, that no doctor will conduct experiments on uninformed patients. The principles require the doctors to hear the patient’s preferences before any treatment is implemented. The informed consent also requires doctors to tell patients the truth even in case of worst diagnosis. This, of course, is a serious problem in many cultures. This issue is discussed in more detail in the section of Medical Secret.

Exercises and review questions • Read the Declaration of Lisbon and make presentation on it. • Explain the anatomical processes that take place in the organisms of diabetics with simple language so that a layman would understand • Search the World Wide Web and take out other international documents that support the principle of informed consent. • What are the two main problems related to the practice of informed consent? • What are the advantages of practicing the principle of informed consent? 75

SECTION 11

MORAL AND LEGAL ISSUES OF ABORTION

*** After completing this chapter you should be able to: • define what is abortion • tell what are the arguments against abortion • tell what are the arguments for abortion • suggest practical solutions in different social settings

The topic of abortion is one of the most discussed topics of medical ethics. Abortion is the artificial termination of pregnancy. There have been multiple reasons to claim both that abortion should not be legalized and visa versa that it should be legalized.

Arguments against abortion* Abortion is a simple murder The most common argument against abortion is that abortion is a synonym of murder. The defenders of this argument believe that the human embryo is a human being from the moment of conception, and as it is illegal to kill a person, so it must be illegal to kill a child.

Abortion is a means to hide immorality Statistically most children to be born, who are aborted are children from out of wed-lock. Because of this statistic, it is claimed, that indi-

* http://biblescripture.net/Abortion.html 76 viduals who have violated social norms should not now get assistance from the society for aborting the child. In this argument prohibiting abortion, plays the role of a negative sanction. The society needs more children The argument, that “we” need more people in our country or nation, has been stated by key individuals of various nations, countries and in different times. Often times, governments make it their duty to create means for increasing the population of their countries. These means can include financial rewards, legal advantages and other types of social benefits to women who have more than a certain number of children. Similar projects however are justified by the ideologies of the need to increase the population of the nation or country. In this context, any abortion is viewed as a “waste” of national or social potential and thus, criticized. Abortion is a sin World religions such as Christianity and Islam are against abortion, because representatives of these religions claim it is against the will of God. As the first group mentioned in this chapter, they believe that abortion is a murder, however criticize abortion not on a legal level, bur rather religious. Arguments for abortion It is the freedom of individuals Freedom has been a central concept influencing the social life of Eu- rope for at least few centuries. Many Europeans today think that it is their freedom to abort their child if they choose so. They claim that public laws should not impinge their autonomy when deciding a major thing such as having or not having a child. Statistics prove that abortion should be legal Recent analysis and research demonstrate that in countries, where abortion is illegal, and citizens of that country tray to abort their child via alternative means, thus harming their health in addition to getting rid of the child. Because there will always be a great number of women, who want to abort their child, abortion should be legalized. Unwanted children In most cases, when children are a result of a rape, or if the child will be born to socially and financially disadvantaged parents, women prefer to abort the child. The general argument is: it is better to abort

77 the child, rather than to bear them and raise the child in poverty, with disorders or to have the picture of rape throughout the whole life. Balanced approaches Between the two polar standpoints of “aborting the child because it is a simple example of practicing freedom” and “not aborting the child because it is a sin and murder” there is the so-called balanced approach. The basic claim of the balanced approach is as follows: “Abort the child when there are certain objective circumstances and do not abort the child in case of other objective circumstances”. The whole question for the balanced approach is to discover which “certain objective circumstances” make it moral to abort and which don’t. Generally in countries where abortion is legal, it is legal only if certain circumstances are present. These circumstances include: Danger for the mother Sometimes women can damage their health or even die during birth. When medical expertise claims that there is a high risk of such disorders, children are usually aborted. Disabled child Sometimes children can be born with severe mental and physical disorders. In some cases doctors can forecast the child’s health situation and the diseases he/she might have. When there are proofs that the child will be born with disabilities, children are usually aborted. Stage of pregnancy Children can be aborted only during the first few weeks of pregnancy. Scientists and psychologists claim, that human embryos show signs of a living creature only after a few weeks, when the embryo reacts to mother’s voice and has emotions. Islamic theologists, on the other hand, claim that the human embryo does not have a spirit during the first few weeks, then God gives the embryo a spirit, and that is why one can abort a child only during the first few weeks of pregnancy. Unwanted child In many countries, it is allowed to abort a child, which is a result of a rape. In some countries children can be aborted for the poverty of parents as well.

Geography of abortion Obviously different countries, having different economical, political, religious and cultural backgrounds, have different standpoints on the issue of abortion. Moreover, in some countries abortion can be legal, but very severely criticized by general public. Yet in others, the situation can be exactly the opposite. Here is a very brief list of countries with one-word description of legal status of abortion: France – Legalized, Britain – Legalized, Switzerland – Legalized, Denmark – legalized, Hungary – Legalized, Romania – Legalized, Poland – Illegal, Italy – Legalized, Colombia – Illegal, Peru – Illegal, Mexico – Illegal, Russia – Legalized, United States – Legalized, China –Legalized, Australia – Legalized, Brazil – Illegal etc*. Exercises and review questions • Make small groups of 5-6 and prepare a public speech within 15-20 minutes. Each group should protect a specific group: those against abortion, those for abortion and those who protect the balanced approach. • Conduct a mini research and find 5 countries where abortion is illegal • Conduct a research and find the regulations of abortions in your home country • Name 2 arguments against legalizing abortion • Name 2 circumstances that the proponents of balanced approaches take under consideration before allowing to abort a child

* Source http://www.abortionfacts.com/statistics/world_statistics.asp 79

SECTION 12

ETHICAL ISSUES OF GENETIC ENGINEERING AND CLONING

*** After completing this chapter you should be able to: • Tell the deference between genetic engineering and cloning. • Tell the difference between therapeutic cloning and reproductive cloning. • identify some uses of cloning • identify some problems of cloning • Explain what organ transplantation is. • tell what problems cause bioethical debates • tell what are some suggested ways of solving these problems • develop you personal opinion on Christian Bernard case

What is genetic engineering?(70) Genetic engineering is the manipulation of DNA or genes in a living cell or an organism in order to produce desired characteristics and to eliminate unwanted ones. Genetic engineering includes a range of different techniques with many different uses, and can be applied to plants, animals and humans. What is cloning? To answer this question the two types of cloning must be examined: Reproductive cloning (which is the cloning of a whole organism); and Therapeutic cloning (which is the cloning of cells or even organs or other tissue for transplant purposes). 80

The general cloning procedure: How are clones made? Reproductive cloning: In order to make a clone of someone, one needs a living cell and a human egg (ovum). The nucleus of the egg, which contains the DNA, is removed and replaced with the nucleus from the cell of the person/animal to be cloned. A short electrical pulse then stimulates the egg to start dividing and the embryo is then implanted into the womb where it develops into a duplicate of the person that donated the cell nucleus. Clones created in this way are not 100% genetically identical, as there is some DNA from the original egg cell that is found outside the nucleus (mitochondrial DNA). Therapeutic cloning: In therapeutic cloning an embryo is created in the same way as reproductive cloning, but it is not implanted into the womb of a woman. Instead, stem cells are extracted after the embryo starts dividing in the first 14 days after fertilization, which kills the embryo. Stem cells are special cells with the ability to reproduce Yan Willmud and become one of 300 types of cells, e.g., skin, liver cell, hair or blood cells. These cells are then used to grow the specific type of tissue or organ that is needed and has the advantage of being genetically identical to the patient who donated it, eliminating the problem of organ or tissue rejection. Adult stem cells versus embryonic stem cells The problem with embryonic stem cells is that many people feel that by using a human embryo and then killing it, a potential person is killed. It is for this reason that some countries are calling for a global ban on all human cloning, including the use of embryonic stem cells. Potential uses of cloning Currently the risks of cloning outweigh the possible benefits, but there are many different potential uses of human cloning technology:

Replacing organs and other tissues – such as new skin for burn victims, brain cells for those with brain damage, spinal rod cells for the paralyzed and complete new organs (heart, liver, kidney and lungs). People could have their appearance changed using their own cloned tissue and accident victims and amputees could also benefit from this tissue regeneration.

Cloning Diagram How Cloning Works Source: http://static.howstuffworks.com/gif/human-cloning-diagram.gif

Infertility – human cloning provides couples and individuals who are unable to have children with another potential option. Replacement of a lost child – parents who have lost a child through an accident or an illness could clone an identical "replacement" child. Creating "donor" people – cloned people could be created to provide a source of transplant material. Gene therapy – cloning technology could be used to prevent, treat and cure genetic disorders by changing the expression of a person’s genes. This technology may also provide the cure for cancer by revealing how cells are switched on and Dolly the Sheep off. Gene therapy could be used to treat somatic (body) cells where the change is not passed on to children, or germ (egg and sperm) cells where the changes are passed on.

Adult stem cells versus embryonic stem cells The problem with embryonic stem cells is that many people feel that by using a human embryo and then killing it, a potential person is killed. It is for this reason that some countries are calling for a global ban on all human cloning, including the use of embryonic stem cells. Potential uses of cloning Currently the risks of cloning outweigh the possible benefits, but there are many different potential uses of human cloning technology: Replacing organs and other tissues – such as new skin for burn victims, brain cells for those with brain damage, spinal rod cells for the paralyzed and complete new organs (heart, liver, kidney and lungs). People could have their appearance changed using their own cloned tissue and accident victims and amputees could also benefit from this tissue regeneration. Infertility – human cloning provides couples and individuals who are unable to have children with another potential option. Replacement of a lost child – parents who have lost a child through an accident or an illness could clone an identical "replacement" child. Cloning has been used for replacing lost pets. In South Korea the first dogs were cloned for commercial purposes. For quite a huge amount of 83 money, an American writer received five copies of her dear pit-bull that died. Are we on the way to building up commercial agencies for cloning our pets? Whereas some ethicist and scientist do not see any problem behind this, others draw attention to the fact that other type of research in this field –therapeutic cloning that is forbidden in most countries – could be used for more “necessary” purposes. The research on embryos, they claim, would help to promote the therapeutic cloning that is a big chance for people suffering from severe and mostly incurable diseases. However it is said to be unethical. Research on embryos is obviously frightening the society more than the mentioned cloning of dogs. Creating "donor" people – cloned people could be created to provide a source of transplant material. Gene therapy – cloning technology could be used to prevent, treat and cure genetic disorders by changing the expression of a person’s genes. This technology may also provide the cure for cancer by revealing how cells are switched on and off. Gene therapy could be used to treat somatic (body) cells where the change is not passed on to children, or germ (egg and sperm) cells where the changes are passed on. This picture illustrates the fears caused by cloning. Some re- Saving endangered species – by searchers think, that unsuccessful boosting their numbers through cre- cloning attempts can create mon- sters like the one in the picture. ating clones. However, since clones are almost genetically identical, the genetic diversity of the species would not be increased (70).

Reversal of the ageing process – once more is understood about the role that our genes play in the ageing process. However, some of the above uses carry with them some serious ethical implications. Problems with cloning techniques

Dolly the sheep was created in 1996 using the cloning methods outlined above. Although Dolly was born looking normal, she has suffered from several problems associated with the cloning technique, including premature arthritis, which is thought to be a side- effect of the cloning. Other problems with the current cloning techniques include: Low success rate: Dolly the sheep was successfully cloned; it took 276 unsuccessful attempts before it worked. Similar work on mice and other mam- mals has also produced the same statistics. To date, the success rate (on animals) is 3-4%. Tumors: Embryonic stem cells are unstable and difficult to control. They Jean Dossie have a tendency to uncontrollably di- vide leading to tumors/cancer. Genetic defects: Although the original DNA from an embryo is removed and replaced with the nucleus from the person to be cloned, some DNA from the original embryo remains in the form of mitochondrial DNA. This can lead to genetic defects that are not fully understood and which are only seen in later life.

Over-growth syndrome: Clones of animals are larger than average at birth, which can be risky for the mother.

Premature ageing: The age of a clone is calculated by taking its birth age and then adding the age of the original from which it was cloned. Although Dolly was born in 1996, she originates from the udder of a six year- old ewe and so her total genetic age is almost 13. Massive quantities of human eggs required: If applied to humans, the current method of cloning would use a vast number of human eggs. To provide these eggs, women would have to become "egg factories", and harvesting them is both painful and dangerous. If adult stem cells

85 were used, then human eggs would not be required as cells could be obtained from th e patient without harming them. Reduction in adaptability: Since, by nature, a clone is a copy of another person, there would be no unique genetic combinations intro- duced into the human gene pool if human cloning was undertaken on a large scale. Therefore, if a contagious disease struck for which there was no cure, all the clones would be wiped out.

Insertion of the gene: In gene therapy where a healthy gene can be used to replace a defective gene, viruses are usually used to insert the gene into the person’s cells. The virus injects the healthy DNA into the cells and the genetic defect is corrected. However, this is not always successful as the virus cannot always be controlled and has triggered leukemia in a recent clinical trial in France.

Lack of knowledge: Although the Human Genome Project has mapped out where the different genes are, a lot more information is needed on their functions. In some cases, a single gene may have more than one function, and in others several genes can cause a genetic disease.

Moral issues: There is a general fear that cloning will have overall demoralizing influence on society. Once people learn ways to make people, replace a dying or a dead child, people will also lose the sense of value of human life.

Geography of cloning: where is cloning allowed? Because cloning is a promising research program many countries are interested in learning to clone organisms or organs. On the other hand, cloning is expensive and can cause unprecedented problems, thus not all countries allow cloning. China, for example allows both reproductive and therapeutic cloning, USA allows cloning but does not provide any government funding and as a result very little cloning research is conducted in USA, Germany has a unique approach: cloning is allowed if and only if embryos are imported from abroad, UK allows therapeutic cloning only and so forth. Because there are different opportunities for cloning and conducting cloning research in different countries, there is a big migration flow of scientists, who travel from one country to the other to do research.

Moral Issues of Organ Transplantation Organ transplantation is one of the medical problems that came into existence in the 20th century, thanks to the advancement of medical technology and medical science in general. Organ transplantation is the transferee of a specific organ from body to another living body either to improve or to make the life of the second one longer. The person, from whose body the organ is taken, is called donor. The organism which receives the organ as a result of transplantation is called recipient.

Uses of organ transplantation4 Organ transplantation is surely one of the major achievements of medical science and has numerous uses. A huge number of patients with heart and liver problems are saved each year thanks to this methodology. As science develops the number of transplanted organs as well as the accuracy and reliability of transplantation also grow. However, much work needs to be done in this respect. One of the major problems is the overall lack of organs to be transplanted: an average of 30% of heart and liver transfer candidates die waiting for an organ to be transplanted. Another problem is that organ transplantation is generally very expensive service, and thus only citizens of developed countries and only the rich among them can have transplanted organs.

Suggestions to improve the organ transplantation system (70). There have been a few suggestions as to how improve the situation with organ transplantation.

Donor Cards In countries where organ transplantation is legal, doctors, however, get the agreement of the dying patient or his/her relatives before trans- planting any organ on someone else. In some cases, an urgent decision needs to be made, and if there are no relatives and the patient is unconscious, all his/her organs become useless. To solve this situation the concept of Donor Cards was suggested. A donor card is a card that is usually attached to an ID card, most of the time, the driving license. On this card, the patient gives permission for using his/her organs for medical purposes after death. This way, the

4 Bernard Lo, Ethical Dilemmas, pp. 87 doctor does not need to ask for permission from the patient’s relatives and family. Many people, though, refuse to sign donor cards, because they fear that their organs will be used before they are dead.

Presumed consent Some people have suggested practicing the principle of presumed consent: that is to use one’s organs for medical purposes, if he/she has not signed anything, stating that he/she is against it. Although logically correct, many refuse to initiate it, for various moral reasons.

Live donors To harvest more organs for transplantation purposes, a suggestion was made to harvest organs from living donors. Organs such as kidneys for example, can be harvested from a living person without causing major damages to the donor. This suggestion is practiced in many countries, however it is vulnerable because of a few aspects: a) there have been cases when a “donor” was forced to become one; b) sometimes after the transplantation problems arise between the donor and the recipient. The donor feels that he has the right of an “ownership” and the recipient feels indebted. To solve these problems between the donor and the recipient, it was suggested to make the process recieval and donation anonymous. This relieves the concerns of the recipient and most cases donors as well. Usually the live donors are family members, however, there has been suggested to harvest organs from strangers for an amount of money. There is a suggestion to use the financial incentive for dying people as well.

Changing the definition of death Generally a patient is considered to be dead when his/her brain stops sending impulses to other parts of the body. In such cases, doctors sometimes do not have enough time to retrieve organs before they become useless. There have been suggestions to change the definition of death to include adults in a persistent vegetative state and anencephaly infants.

Exercises and review questions • What are the current legal regulations of gene engineering and cloning in your home country? • What other potential uses of cloning can you think of? • What is the danger of ethical degradation caused by cloning? • Explain what organ transplantation is. • Indicate problems that cause bioethical debates • What is definition of death? How can the definition of death help to solve the problem of deficit of donated organs? • What is a donor card? • What is the presumed consent? • What are the uses of organ transplantation? • What are the problems related to the principle of presumed consent?

SECTION 13

ISSUES OF LIFE AND DEATH

*** After completing this chapter you should be able to: a. explain the way world religions interpret life and death, b. describe some forms of “eternal life”, c. distinguish the ideas of some outstanding thinkers.

For some people death is a punishment, for others it is a grace and for some others it is something good.

Life and death are unalienable from our thought. Philosophers, prophets, developers of art and literature as well as doctors have expressed their opinions about his issue. Some have considered life a suffering (Buddha, Schopenhauer), others a dream (Plato, Pascal) and some have considered it a hollow and stupid joke (Lermontov). To avoid from long windedness Shakespeare’s words could be used here. “Life is a walking shadow, a poor actor, who gets excited at his time on the stage and then makes no noise. Life is a fairy tale told by an idiot, it is full of rattle and fury, and is meaningless.” Another prominent thinker, Mahatma Gandhi mentioned on an occasion “We do not know what is better, to live or to die. We must treat both life and death in the same way. This is the ideal way” (9). World religions and the issue of life and death The Christian conception of meaning of life, of death and eternal life derives from the well known phrase from the Old Testament “The day of the death is better than the day of birth” and Christ’s message in the New Testament “I have the keys to hell and death.”

According to Christianity a person’s eternity is possible only through resurrection. The way to resurrection was hinted to us by Je- sus Christ by his crucifixion and resurrection. Therefore, the purpose of life is embodied in the way to eternal life. When someone is not conscious of this his life turns into a meaningless dream and an empty occupation. Life on this earth is nothing else but preparation a test before the eternal life. No surprise that the Gospel says: “Be ready, no matter how much you live and act, the son of man will come.” Death is not an end, it is a passage from one world to the other full of joy or suffering. According to one of the prophets “A dying person is a rising moon, which shines on another world.” A form of eternal life hangs on Agaster an “eternal Jew.” When under the heavy cross Jesus was going up to Mount Goghgota and wanted to have a little rest, Agaster, who was standing next to others told him: “Go, go!”Because of this, he was punished and was not given a chance to rest in a tomb. He was punished to roam all over the world and to wait for the 2nd coming of Jesus Christ, because only Christ could free him from the suffering of roaming endlessly. Eden, or paradise is described as absolute lack of disease, death, hunger, cold, poverty, enmity and hatred. Life is eternal there, there is no hard word, happiness is without sorrow, health is without disease and honor is without danger. All people have the teenager vigor, all are in Christ’s age, they are soothed by love, they enjoy the peace and “love each others as themselves.” The gospel of Luke describes death as follows: “God is not the God for the dead, but a God for the alive, because everyone is alive for Him.” The command “Do not kill” as presented in Bible is related to condemnation of suicide. The church informs that those who commit suicide are condemned to eternal destruction and are denied the right to be buried according to church ceremony. Even F. Nietzsche accepted that Christianity has struggled “against the insatiable thirst of suicide which was so widespread during the time when Christianity was born.” After examining the widespread phenomenon of suicide in ancient civilizations, the founder of sociology of religion Frenchman E. Durk- heim concludes that in among circumstances leading to suicide old age

91 and diseases have a special role. This is not so in Armenia. During the past few years the number of suicides by younger men causes a great amount of concern (75). According to Islam, man was created by omnipotent Allah, which is first of all a merciful God. Allah has given the following answer to the question: “Will I stay in the memory of people after I die?” “Will not remember the man, that we have created him, and before that, he was nothing.” Unlike in Christianity, Islam values the life in this world. However, on the Judgment day everyone will be resurrected and will be judged. The faith in transcendental life is considered to be necessary because in this case the man estimates his deeds from the point of view of eternity and not from the standpoint of his interests. The destruction of one world means creation of a new world. All deeds by an individual will be presented to Allah for judgment. People who are morally chaste will get their compensation. Islam is also determined against suicide. Koran depicts paradise and hell with vibrant colors to make sure that those who are just are satisfied and those who are guilty receive their due punishment. Christian and Islamic views on death and immortality are essentially different from that of Buddhism. Buddha does not answer the question “Whether the one who knows the truth is immortal?” Only one form of “miraculous immortality” is known the Nirvana, as an embodiment of substance that has no characteristic of the transcendental. To put it dif- ferently, the Buddhist culture is a unique religious ceremony, because the supreme joy and the desired purpose of life is outside life, it is in the non-existent, in Nirvana. Buddhism does not deny the idea of reincarnation, which originates from Brahmanism. According to this idea all creatures are reborn after death. They are born with a new image, an image of a human, animal, deity, spirit etc. However Buddhism brings its corrections. If Brah- mans claim that through different ceremonies defined for different castes, people may achieve “good rebirths”, Buddhism claims that every rebirth is an unavoidable evil. For a Buddhist, the supreme purpose is to stop the circle of rebirths and to achieve Nirvana (non-existence).

The person is comprehended as a sum of drahms which is in the everlasting flow of re-embodiment. It follows from here that the chain of rebirth is purposeless. “Dhamapada” claims that a rebirth is a resuffering. The way out is Nirvana, the desired “island”, which is in the depth of human heart, where “there is nothing”, and “nothing is desired.” As Buddha as once pointed out. “The one day of a person, who has seen the way to immortality, is preferable then the century long existence of the person, who has not seen the supreme life.5” Majority of people are unable to reach Nirvana at once. Following the example of Buddha, the living creature must continuously pass through re-embodiments to reach the “supreme wisdom.” When one reaches this stage, one can step out from the “whirlpool of existence” and put an end to the circle of reincarnations.

The issue of life and death in philosophy From the moment of birth human life progresses towards death. The only stable thing in this world is death, all ethical and other types of values change in different places, times and other circumstances. But death stays the only unchanging thing in our life. It should be mentioned here the words of great H. Tumanian: “There is only one certain thing in this world, and it is that there is nothing certain.” Another great Armenian poet A. Isahakyan writes: Every second of our life Causes a slight and yet incurable wound And the last, the last awful second Kills us with a strong strike. Ortega I. Gasset, the great Spanish philosopher and thinker describes the human being not as a body and not as a soul, but as a unique human drama. And truly in this sense each individual’s life is full of not only with drama but also by tragedy. No matter how successful a man’s personal life is, no matter how long it is, it has an inevitable end. The issues of death and potential immortality have always caused philosophic contemplations. And the results will be won- derful, if people estimate their worldly deeds from the standpoint of eternity. The human being is condemned to think of life and death. This fact differentiates humans from animals. In general, death is a

93 unique compensation for the gradual growth of complexity of biological life. Creatures composed of one single cell are practically immortal and in this sense amoebas are happy creatures. When the organism becomes multi-celled, a mechanism of self- distraction is incorporated into it. It is related to genome and its peculiarities. Human beings try to theoretically deny it, to prove the myth of his immortality. We are unable to agree with the idea, that the time will come, when we will die and leave this world, where life is everywhere. The man thinks that it is not about himself, it is too far from him. No surprise that the comprehension of the limitedness of human life leads us to a mournful state. L. Tolstoy believed that even the family love is unable to comfort the soul, that it is a “useless hope. And why educate children, if they are to find themselves in the same state as their father in the future? We are unable to hide this undeniable truth from children and the truth is that death is inevitable.”

Life, Death and Immortality: the Relation of the Biological and the Spiritual. The hypothesis of pansperm is well known to the public, according to which life and death are ceaselessly reproduced in the universe.

SECTION 14

EUTHANASIA. ISSUES OF SOCIOLOGY OF LIFE

*** After completing this chapter you should be able to: • define what is euthanasia • define types of euthanasia • understand arguments for and against euthanasia • analyze difficult problems about the relationship of life and death • decision making regarding the end of life • euthanasia in Armenia in the Middle Ages

The problem of euthanasia is probably one of the oldest problems in medical ethics. In past, when wars and battles happened in open fields and ended with thousands and thousands of wounded soldiers, there were special military duties for walking through the fields and killing the wounded. This was viewed as an act of mercy. This act was done by a sword which looked like a cross and was named misercordia. Euthanasia is the practice of helping the person die because he/she suffers a great amount of pain or because his/her dignity is endangered. A debate on the morality of suicide is related to doctor-patient relation. Should the doctor give poison to the patient, or not? It has re- mained an actual and unsolved problem for many years. Even today there are doctors and medical schools that keep asking: Which is better for the patient who suffers from an incurable disease, e.g. cancer, when modern medicine is powerless.

The problem of euthanasia can be stated as follows: “Are there any reasonable grounds, which make euthanasia a morally justified act?” This question divides world population into two opposing armies.

Arguments for euthanasia

Life is not only breathing lungs, and beating heart The advocates of this argument claim that life is much more than a basic physiological phenomenon. To live for them, is to enjoy life, to participate in the social life of their community, to be a full member of family etc. When a person is in a vegetative state, therefore, a person is not living. Thus it is better to help him part from this world. It is better to die, rather than suffer this pain Some diseases, such as cancer, can be very painful during their last stages. So it has been claimed by a large number of people, that it would be better to help them die easily, rather than making them suffer before they Mkhitar Heratsi and die. Nerses the Graceful Medical service is expensive Sometimes, it is very expensive to keep people alive and it seems morally wrong to keep them alive, knowing, that they will eventually die, after “taking” another amount of dollars. Instead, the society could use this money for those, who can eventually recover. In fact, this is an economical argument for euthanasia.

Arguments against euthanasia A request for assisted suicide is a cry for help. It is in reality a call for counseling, assistance, and positive alternatives as solutions for very real problems. Suicidal Intent is typically transient. Of those who attempt suicide but are stopped, less than 4 percent go on to kill themselves in the next

96 five years; less than 11 percent will commit suicide over the next 35 years. Pain is controllable. Modern medicine has the ability to control pain. A person who seeks to kill him or herself to avoid pain does not need legalized assisted suicide but a doctor better trained in alleviating pain. You don't solve problems by getting rid of the people to whom the problems happen. The more difficult but humane solution to human suffering is to address the problems. Euthanasia is a murder Euthanasia, no matter how it is worded, is in fact a synonym of murder. Euthanasia is a sin According to advocates of this view, God has created humans, God has given individuals their life, and God will take this life away. To practice euthanasia, is to try interfering with God’s business and is a sin. Euthanasia is demoralizing Euthanasia is interpreted as something anti- humanistic under this argument. Once euthanasia is legal, it will gradually become more and more popular, and thus, people will gradually be less compassionate about their dying keen. The overall value of human life will thus be decreased. Legalizing euthanasia, will cause massive abuses There is a fear, that once euthanasia is legal, there will be people who will argue for much broader practice of euthanasia. Also, there is a fear, that it will be practice on people, who still Buddha have the chance to recover. Types of euthanasia There are three main types of euthanasia: active euthanasia, passive euthanasia and assisted suicide. Active euthanasia In case of active euthanasia, the doctor is the acting agent. He/she makes a lethal injection so that the patient dies shortly after the injection.

Passive euthanasia In case of passive euthanasia, the doctor remains “passive”. He/she stops helping the patient (for example, turns off the respiratory machine) and the patient dies shortly after the act.

Assisted Suicide In case of assisted suicide, the doctor creates all “human” conditions for committing suicide and the patient, eventually makes a painless suicide. Euthanasia in practice In countries where euthanasia is allowed, it is allowed only under certain circumstances. The practice of euthanasia is strictly regulated by law. An act of euthanasia can be considered to be legal if: • the patient is terminally ill • the patient suffers a great amount of pain • the patient has given his/her informed agreement • The patient has given his/her agreement with his/her free will etc. Euthanasia in Fascist Germany One of the most influential papers on medical issues in Fascist Ger- many was written by Leo Alexander. His complete article “Medical Science under Dictatorship” is available in the Internet*. Leo Alexander claims that science under dictatorship becomes sub- ordinated to the philosophy of the dictatorship (69). Irrespective of other ideological trappings, the guiding philosophic principle of recent dictatorships, including that of the Nazis, has been Hegelian in that what has been considered "rational utility" and corresponding doctrine and planning has replaced moral, ethical and religious values. Nazi propaganda was highly effective in perverting public opinion and public conscience, in a remarkably short time. In the medical profession this expressed itself in a rapid decline in standards of professional ethics. Medical science in Nazi Germany collaborated with this Hegelian trend particularly in the following enterprises: the mass extermination of the chronically sick in the interest of saving "useless" expenses to the

* Dear reader, this article will help you better understand social/political/legal and bioethical aspects of medical practice. The article was adopted from: http://www.restoringourheritage.com/articles/nej_medicaldictatorship.pdf 98 community as a whole; the mass extermination of those considered socially disturbing or racially and ideologically unwanted; the individual, inconspicuous extermination of those considered disloyal within the ruling group; and the ruthless use of "human experimental material" for medico-military research (69). Even before the Nazis took open charge in Germany, a propaganda barrage was directed against the traditional compassionate nineteenth-century attitudes toward the chronically ill, and for the adoption of a utilitarian, Hegelian point of view. Sterilization and euthanasia of persons with chronic mental illnesses was discussed at a meeting of Bavarian psychiatrists in 1931.[1] By 1936 extermination of the physically or Jack Kevorkian socially unfit was so openly accepted that its One of the most influen- practicetial pro-euthanasia was mentioned actors incidentally in an article published in an official Germanin the world. medical journal.[2] Lay opinion was not neglected in this campaign. The first direct order for euthanasia was issued by Hitler on Sep- tember 1, 1939, and an organization was set up to execute the program. Dr. Karl Brandt headed the medical section, and Phillip Bouhler the administrative section. All state institutions were required to report on patients who had been ill five years or more and who were unable to work, by filling out questionnaires giving name, race, marital status, nationality, next of kin, whether regularly visited and by whom, who bore financial responsibility and so forth. The decision regarding which patients should be killed was made entirely on the basis of this brief information by expert consultants, most of whom were professors of psychiatry in the key universities. These consultants never saw the patients themselves. A large part of this was devoted to the science of destroying and preventing life, for which I have proposed the term "ktenology," the science of killing. In the course of this ktenologic research, methods of mass killing and mass sterilization were investigated and developed for use against non-German peoples or Germans who were considered useless.

Sterilization methods were widely investigated, but proved impractical in experiments conducted in concentration camps. A rapid method developed for sterilization of females, which could be accomplished in the course of a regular health examination, was the intra-uterine injection of various chemicals. Numerous mixtures were tried, some with iodopine and others containing barium; another was most likely silver nitrate with iodized oil, because the result could be ascertained by x-ray examination. The injections were extremely painful, and a number of women died in the course of the experiments. Another chapter in Nazi scientific research was that aimed to aid the military forces. Many of these ideas originated with Himmler, who fan- cied himself a scientist. When Himmler learned that the cause of death of most SS men on the battlefield was hemorrhage, he instructed Dr. Sigmund Rascher to search for a blood coagulant that might be given before the men went into action. Rascher tested this coagulant when it was developed by clocking the number of drops emanating from freshly cut amputation stumps of living and conscious prisoners at the cremato- rium of Dachau concentration camp and by shooting Russian prisoners of war through the spleen. Live dissections were a feature of another experimental study designed to show the effects of explosive decompression. A mobile decompression chamber was used. It was found that when subjects were made to descend from altitudes of 40,000 to 60,000 feet without oxygen, severe symptoms of cerebral dysfunction occurred at first convulsions, then unconsciousness in which the body was hang- ing limp and later, after wakening, temporary blindness, paralysis or severe confusional twilight states. Rascher, who wanted to find out whether these symptoms were due to anoxic changes or to other causes, did what appeared to him the most simple thing: he placed the subjects of the experiment under water and dissected them while the heart was still beating, demonstrating air embolism in the blood vessels of the heart, liver, chest wall and brain. Another part of Dr. Rascher's research, carried out in collaboration with Holzlochner and Finke, concerned shock from exposure to cold. It was known that military person- nel generally did not survive immersion in the North Sea for more than sixty to a hundred minutes. Rascher therefore attempted to duplicate these conditions at Dachau concentration camp and used about 300 prisoners in experiments on shock from exposure to cold; of these 80 or

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90 were killed. (The figures do not include persons killed during mass experiments on exposure to cold outdoors.) In one report on this work Rascher asked permission to shift these experiments from Dachau to Auschwitz, a larger camp where they might cause less disturbance because the subjects shrieked from pain when their extremities froze white. The results, like so many of those obtained in the Nazi research program, are not dependable. In his report Rascher stated that it took from fifty three to a hundred minutes to kill a human being by immersion in ice water a time closely in agreement with the known survival period in the North Sea. Inspection of his own experimental records and statements made to me by his close associates showed that it actually took from eighty minutes to five or six hours to kill an undressed person in such a manner, whereas a man in full aviator's dress took six or seven hours to kill. Obviously, Rascher dressed up his findings to fore- stall criticism, although any scientific man should have known that during actual exposure many other factors, including greater convection of heat due to the motion of water, would affect the time of survival. An important feature of the experiments performed in concentration camps is the fact that they not only represented a ruthless and callous pursuit of legitimate scientific goals but also were motivated by rather sinister practical ulterior political and personal purposes, arising out of the requirements and problems of the administration of totalitarian rule. Why did men like Professor Gebhardt lend themselves to such experiments? The reasons are fairly simple and practical, no surprise to anyone familiar with the evidence of fear, hostility, suspicion, rivalry and intrigue, the fratricidal struggle euphemistically termed the "self- selection of leaders," that went on within the ranks of the ruling Nazi party and the SS. The answer was fairly simple and logical. Dr. Gebhardt performed these experiments to clear himself of the suspicion that he had been contributing to the death of SS General Reinhard ("The Hangman") Heydrich, either negligently or deliberately, by fail- ing to treat his wound infection with sulfonamides. After Heydrich died from gas gangrene, Himmler himself told Dr. Gebhardt that the only way in which he could prove that Heydrich's death was "fate- determined" was by carrying out a "large-scale experiment" in prisoners, which would prove or disprove that people died from gas gangrene irrespective of whether they were treated sulfonamides or not. Dr.

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Sigmund Rascher did not become the notorious vivisectionist of Da- chau concentration camp and the willing tool of Himmler's research interests until he had been forbidden to use the facilities of the Patho- logical Institute of the University of Munich because he was suspected of having Communist sympathies. Then he was ready to go all out and to do anything merely to regain acceptance by the Nazi party and the SS. These cases illustrate a method consciously and methodically used in the SS, an age-old method used by criminal gangs everywhere: that of making suspects of disloyalty clear themselves by participation in a crime that would definitely and irrevocably tie them to the organization. In the SS this process of reinforcement of group cohesion was called "Blukitt" (blood-cement), a term that Hitler himself is said to have obtained from a book on Genghis Khan in which this technic was emphasized. The important lesson here is that this motivation, with which one is familiar in ordinary crimes, applies also to war crimes and to ideologically conditioned crimes against humanity–namely, that fear and cowardice, especially fear of punishment or of ostracism by the group, are often more important motives than simple ferocity or aggressive- ness. The question that this fact prompts is whether there are any danger signs that American physicians have also been infected with Hegelian, cold-blooded, utilitarian philosophy and whether early traces of it can be detected in their medical thinking that may make them vulnerable to departures of the type that occurred in Germany. Basic attitudes must be examined dispassionately. The original concept of medicine and nursing was not based on any rational or feasible likelihood that they could actually cure and restore but rather on an essentially maternal or religious idea. The Good Samaritan had no thought of nor did he actually care whether he could restore working capacity. He was merely motivated by the compassion in alleviating suffering. Bernal[17] states that prior to the advent of scientific medicine, the physician's main function was to give hope to the patient and to relieve his relatives of responsibility. Gradually, in all civilized countries, medicine has moved away from this position, strangely enough in direct proportion to man's actual ability to perform feats that would have been plain miracles in days of old. However, with this increased efficiency based on scientific development went a subtle change in attitude. Physicians have become dan-

102 gerously close to being mere technicians of rehabilitation. This essentially Hegelian rational attitude has led them to make certain distinc- tions in the handling of acute and chronic diseases. The patient with the latter carries an obvious stigma as the one less likely to be fully rehabilitable for social usefulness. In an increasingly utilitarian society these patients are being looked down upon with increasing definiteness as unwanted ballast. A certain amount of rather open contempt for the people who cannot be rehabilitated with present knowledge has developed. This is probably due to a good deal of unconscious hostility, because these people for whom there seem to be no effective remedies have become a threat to newly acquired delusions of omnipotence. Hospitals like to limit themselves to the care of patients who can be fully rehabilitated, and the patient whose full rehabilitation is unlikely finds himself, at least in the best and most advanced centers of healing, as a second-class patient faced with a reluctance on the part of both the visiting and the house staff to suggest and apply therapeutic procedures that are not likely to bring about immediately striking results in terms of recovery (69).

Exercises and Review Questions • Do a research and find out the countries where euthanasia is legal. • How many people are subjected to euthanasia in the Nether- lands each year? • Who Is Dr. Death? Prepare a short presentation about him. • What are the types of euthanasia? • What are the arguments against euthanasia?

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*** After completing this chapter you will be able to: • define what the living will is, • tell what situations is living will usually applied to, • tell what are the difficulties with using the living will are, • define the terms health care proxy and “Do not resuscitate order”.

The issue of Euthanasia has emerged in Ancient times and has always caused tense discussions. The term “Euthanasia” was suggested by English philosopher Francis Bacon (XVI-XVII centuries). The term is based on Greek words (Eu – good, thanatos- death). In a “Proclaimation about Euthanasia” adopted by the Doctrine on May 5, 1980 the following definition of the term is given: “Euthana- sia is any action or passive state which leads to death intentionally. This means, that euthanasia is the intentional killing of a person by a doctor.” These words do not regard suicide or death as a result of painkillers.

What is living will?* Through advances in medical technology, some patients who for- merly would have died can now be kept alive by artificial means. Sometimes a patient may desire such treatment because it is a temporary measure potentially leading to the restoration of health. At other times, such treatment may be undesirable because it may only prolong the process of dying rather than restore the patient to an acceptable quality of life. In any case, each person is seen under the law as having the personal right to decide whether to institute, continue or terminate such treatment. As long as a patient is mentally competent, he or she can be consulted about desired treatment. When a patient has lost the capacity to communicate, however, the situation is different. For such cases, the living will is used. The living will simply documents a person's wishes concerning treatment when those wishes can no longer be personally communicated.

* www.wma.net 104

Many people, knowing that there may be conditions under which they would not want treatment, communicate their wishes while they are able to do so. Some people know now that they will never want a certain kind of treatment under any circumstances, this attitude is rare, since many medical conditions are reversible and most would agree that even an unpleasant treatment could be tolerated for a short time. More commonly, people have conditional wishes. That is, they wish to receive or refuse specific treatments under certain circumstances. There are generally two broad types of situations in which a health care declaration may apply. The first is terminal illness; the second is permanent disability.

Terminal Illness In terminal illness (where death is expected in a relatively short time), people often fear treatment that only extends life without restor- ing a desired quality of life. While such treatment may be acceptable for some, for others it is not. If you lose the ability to communicate, your doctors may assume you want your life extended as long as possible. If one prefers a shorter, but more comfortable life during a terminal illness, one can request it. Most standard health care declarations do address terminal illness, and most doctors readily respect the wishes expressed with respect to terminal care.

Permanent Disability Unfortunately, many health care declarations fail to address the other major fear permanent disability. It is more difficult to reach any con- sensus regarding permanent disability for two reasons. One reason is that doctors and other health care workers may attempt to apply their own value system to a patient's case. While they may agree to withhold attempts to prolong life in terminal illness, they may vigorously oppose withholding treatment for chronic illness. The second reason is that the variety of chronic impairments is so great that individuals widely disagree as to what constitutes an intolerable situation. For example, some may dread a stroke that leaves them unable to communicate. Others fear permanent dependency on others or the impaired thinking resulting from dementia or Alzheimer's. Simply

105 put, the circumstances that trigger the application of a health care declaration to chronic illness are different for each individual.

Determining Permanence or Irreversibility How to determine permanence or irreversibility? Unfortunately, in many cases, the best that can be done is to observe for a period of time. Failure to improve over the short run may indicate a poor prognosis in certain types of cases. The best example is brain damage due to lack of oxygen (such as after a cardiac arrest, or a stroke). The longer a patient is unconscious, the less likely it is that full capacity will be regained. After such an event, it is impossible to predict immediately who will regain prior capacity, and who will remain in a severely impaired state. Most people who will improve significantly show signs of progress in the first few days, and generally within the first two weeks. It is usually reasonable to observe a patient for this period, knowing that someone who does not wake up after two weeks is more likely to remain in a coma or a persistent vegetative state. Fortunately, this type of predictor (waiting and watching) leads itself well to the need for specificity in the health care declaration (Living Will). One can easily pick a time limit and state it in the document. The important thing to remember is that a time limit (even a long one) pro- tects against permanent maintenance in an undesirable state since a time limit is an unequivocal instruction. Many people decide to write a living will after witnessing the medical treatment of a friend or relative. This first hand experience may be important in providing emphasis and weight to personal statements. However, no two sets of circumstances are identical. And this circum- stance should be taken under consideration when writing a living will. It is generally recommended to consult with family and close friends before writing the will. Being specific in the health care declaration is very important, because unless the declaration is specific and well written it will yield room for ambiguity and hence, will not serve to its true purpose.

Why do many people refuse treatment? There are basically two broad reasons to refuse a certain treatment. The first is that the benefit of the treatment is not great enough to justi-

106 fy its risk or discomfort. This is the basis for most treatment decisions, and involves the individual attitudes each patient will bring to the decision. Some people will endure unpleasant and risky treatments for a chance to live longer; others prefer a more comfortable, shorter life, using the least possible medical intervention. The second reason to refuse medical treatment is that it will prolong life under intolerable conditions. Even an easily tolerated treatment with minimal discomfort might be unacceptable if it prolongs life in the face of unwanted circumstances. A treatment that easily passes the risk/benefit or burden/benefit test may still be refused because it only prolongs a life that is hopelessly dismal.

People, who are thinking about writing a living will, are recommended to: • Communicate their feelings to their religious advisor, to their attorney for friends • Communicate with physicians, especially if one has a family doctor or a personal physician • Communicate with their families. Even if the living will does not fit to the situation, where the patient finds himself/herself, family and friends, will be there to make “corrections” based on their experience, with the patient and their knowledge of the patient. Communicating decisions to family members also helps to cool their emotions, when the real need of the living will occurs.

Because the health care declarations and living wills sometimes do not match the real circumstances in which the patients find themselves, the concept of health care proxy has emerged. A health care proxy is an individual who is authorized to make health care decisions for him or her when he or she has been determined to be incapable of making such decisions. The law puts primary emphasis on the patient's previously expressed wishes, but except for a decision to withdraw or withhold food and water, also allows the agent to make decisions in the patient's "best interest" if an issue arises that the patient never discussed.

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A last practice, parallel to the living will is the “Do Not Resuscitate Order” These orders apply only to cardiopulmonary resuscitation and there are specific rules concerning how they are to be written and who may authorize them. Briefly, if while in a hospital one’s heart stops beating and one stops breathing, a team will immediately attempt to restore normal heartbeat (resuscitation) and breathing. This attempt will happen automatically unless such treatment is refused in advance. The is- suance of a DNR order is the method prescribed by law for such a refusal. Exercises and review questions • Prepare a research paper on health care practices in England, in France, in Germany and in the USA • What is a “Do not resuscitate order”? • What is a health care proxy? • What are some recommendations to a person who wants to write a living will? • Is there a living will in Armenia?

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SECTION 15

EUTHANASIA IN ARMENIA

*** The problem of euthanasia can be solved only after taking into account traditions, customs, cultures, psychology, mentality as well as social economic condition of the society. There are many conceptions, thoughts and ideas of medieval Arme- nian philosophers and physicians that deal with medicine and ethics. Davit Anhakht’s ideas are among them. In 1980 the 1500th anniversary of Davit Anhakht (Invincible), was gloriously celebrated by UNESCO. In the 9th chapter of his book, Definitions (Statement) of Philosophy, developing the ideas of Armenian philosopher Nerses the Great (5th Century AD), he asked the same question and answered: “As the good captain, who displays his skills not in the peaceful sea, but during the storm, the enthusias- tic soul bravely goes towards the trial”. Anhakht’s idea has the same philosophical background as the famous “Oath of Hippoc- Nerses the Great rates” where the physician vows: “I promise not to give killing remedy to anybody despite their wish”. And the doctor, who, however, breaks his oath, is worth not only the damnation of medical gods and people but also state punishment, even death sen- tence. We can read about it in the “Book of Necessity” by great Arme- nian historian from the 5th century, Movses Khorenatsy (Movses from Khoren) (23).

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It is known that the followers of stoic philosophy (One of the ancient branches of Greek philosophy, which were well known for their moral teach- ings) justified suicide in 9 cases (hunger, loss of close relatives, disaster, insult of dignity, incurable disease, marasmus etc.). The last two cases have direct connection with medicine. The stoics said: “If a person suffers from an incurable disease and there is no remedy to cure it, he acts morally if he kills himself”. A stoic philosopher, who was partly paralyzed, asked Jul- ius Caesar “Half of my body died the other part still lives. Do your best please, order either to treat me or to kill”.

If a man commits suicide in his old age, David the Invincible when he begins to utter heterogeneous, not distinct words, he acts morally killing himself. These are typical symptoms of athero- sclerosis and paralysis, moreover, it is not excluded that the latter is resulted from malignant tumor of the spinal column in the stage of metastases. Thus, in Greek thought, euthanasia was supported in some cases (23). Unlike Greeks, who accept euthanasia in some cases, no Armenian medieval philosopher or physician accepted it. They denied suicide saying: “The trials wherever they occur, exist in order to test human soul and not to kill him”. It should be mentioned that Armenian medieval thinkers Mkhitar Gosh and Smbat Mkhitar Gosh Goondstable wrote in articles 119 and 154 of “Code of Law”: “The physician who injures the patient’s health on purpose and doesn’t give sufficient knowledge to his students should be sentenced”. I would like to draw your attention to this delicate problem.

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Thus physician’s responsibility has a special place in Armenian legislation, which testifies to the high level of Armenian medical school (23). The law “Medical Aid and Service in Republic of Armenia” was adopted in March 1996 and it forbids to quicken the patient’s death despite the patient’s or his/her relatives’ preferences. According to the results of our sociological inquiry, 80% of Arme- nian respondents are against euthanasia, 10% appreciates it and 10% hesitates taking into account the severity of the issue. The fact that majority of respondents (students, tutors, scientists etc.) is against euthanasia is due to their mentality as well as cultural, historical and psychological peculiarities of Armenians. As we know, every nation has its culture of death. The social opinion has several layers: Superficial, external layer, which expresses superficial estimation of this problem, which has no connection with exact situations and per- sonalities. Situational level, i.e. it can suggest one step, but larger and inclusive factors should be considered as well. When answers are considered from the personal-situational point of view, the answers begin to differ and change greatly. Those who were against euthanasia don’t exclude it, they even consider it possible and the only way out in separate exact cases, e.g. we ask: “If you were in a severe, hopeless condition, would you like to die, would you prefer euthanasia or not?” the majority answered: “Yes, I would”. Thus, in the oral, verbal level people are against euthanasia, but when the situation is made more personal, respondents do not exclude the possibility of consenting to euthanasia. The positive and negative answers shouldn’t be accepted as unchangeable. There is contradiction between the expressed thoughts and real opinion i.e. they are for euthanasia on verbal level, but practically; personally and individually they are against. Because the society maintains the social opinion, mentality, psychology, the Christian culture that “The God has created, let him take away”, people tend to disagree about euthanasia. It’s impossible not to consider the social opinion. If any of our close relatives is awfully ill, exhausted, suffers and there is nothing to save him, you think: “Poor… it would be better if he died” (by the way, we express our sorrow in this word). But, on the other hand, he does

111 nothing in this aspect (he doesn’t allow himself: “What would the others say?”). This is the contradiction in the social opinion, which testifies to the difference between the expressed words and real opinion. The socio-economic, mental severe conditions, the absence of the future (not seeing any light at the end of the tube) encourage suicide (“Who shall I live for, if Mother is dead, Son was killed, and I was alone…”). These deformations of values influence on man’s decisions. So, there isn’t any ready answer and the following factors should be considered (60): Age (there are critical ages defined for men and women). One is able to overcome it, others not. Peculiarities connected with the fate (Freud says: there are men who are inclined to Tanatos i.e. to death, suicide, pessimism, and are destructive people, whereas there are some other disposed to Eros, who overcome difficulties with smile and humor). The peculiarities of period: e.g. the rise of spiritual awakening at the end of the 1980-s in Armenia, the understanding of national prestige, great sense of civil duty, but quite the contrary picture can be seen in the period of political and social stagnation, wide-spread sense of depression, disappointment, social unprotected situation, a condition when you cannot see even one way out, when you lose your head and are unable to make any decision in this new complicated market relations. There is an expression: “Characteristic picture of life”. From the point of view of sociologists the reality of life is described in this way: When the society transferred from one level into another (no matter higher it is or lower) certain destroying changes take place: old stereo- types are ruined, people cannot find themselves and display their abilities and skills (moreover, we shouldn’t forget that for more than 70 years the former USSR used to say to every person: “you don’t need to think about anything, I think about you instead of you”.) Things have changed during the last decade after the USSR was ruined. Today the state doesn’t say anything to anybody, and man should consider his problems by himself (education, welfare, entertainment, work etc.). The state stands aside and leaves all these problems at your disposal. You are to decide where to study, how to live, what to do. In a word he is given freedom, but he doesn’t know what to do with it. And this is the situation when a man (In his/her middle and old age) meets psychologi-

112 cal difficulty. This is when the majority cannot find their place in life and face to escapism: they escape from reality which is displayed by drug addiction, alcoholism, prostitution and other such phenomena. And here comes the moment when man says: that’s enough, I cannot stand it any more, and I don’t want to live. That’s why the detailed investigation of the causes of increasing rate of suicide can give much to sociologists and psychologists (60).

The peculiarities of cultural environment, social opinion and mentality The investigation of the psychological survey and psychology has shown that there is distinction between the answers: “On the whole I am against it” and “In certain situations I might not be against”. It means that situational analysis should be given to certain social- demographic, mental and other distinguishing features of the patients. We are Christians and we say “No” to euthanasia, but our mentality has distinction, i.e. there aren’t ready descriptions and solutions to all conditions. It looks like the questions given in Kant’s Antinomies: is there God or not: does the world have beginning or not, etc. Trying to answer these questions we occur in contradictions because “for” and “against” factors are equal and it is the moral duty of every thinking human being: “to adopt and believe in God”(7). It is the same in case of euthanasia: it well is right to consider: • the patient’s personal features • psychological delicacy of the social setting • Traditional values and the cultural context, etc. In any case, Armenians, as a Christian nation say “No”.

Exercises and Review Questions • Who was David the Invincible? • In which book did Mkhitar Gosh write about Euthanasia? • In which of his books, does David the Invincible write about Euthanasia? • Whose Ideas are the bases for judgments of David the Invinci- ble?

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• Compare ideas of Armenian medieval thinkers with ancient Greek thinkers. • Compare ideas of Armenian medieval thinkers with medieval thought (if applicable) of your countries. • What does current Armenian law say about euthanasia?

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SECTION 16

PALLIATIVE CARE

*** After completing this chapter you should be able to: a. define what is palliative care, b. explain the need of palliative care service in contemporary society, c. explain difficulties of palliative care research d. Present a general outline of history of palliative care

Euthanasia is one of the main suggested treatment methods (for terminally ill people) that has been widely debated by general public and specialists alike. The other treatment suggested for the terminally ill is the palliative care. The word “palliative” has Latin origin and it means curtain, mask. The idea of palliative care is to hide the unwanted symptoms of the incurable disease from the diseased. From the very beginning of their history the humans have faced the problem of death. In the doctrine of palliative care death is viewed not as a problem but rather a normal occurrence, something that is necessary for a life to be complete. From this point of view, both the life and the death are processes that pene- trate one into the other. From the first moment of life the human being starts to die and when a person dies, s/he starts to live in another way (11). It is a core human desire to take care of someone else. The desire to take care of someone in need is worded as compassion, lave, sympathy etc. Humans have always tried to take care of others and of course their means and ability to do so has always been limited by the historic scope of their intellectual, spiritual and technological capacities. Until very

115 recently, medicine could offer almost nothing for a hurt internal organ, for alleviating pain, for stopping infections etc. 1950s brought a new wave of knowledge and skills to humankind. A few influential medical innovations were made, effective painkillers were discovered. The 1950s were also the rise of intensive psychological and social studies and particularly of studies of dying people. The first institutions for taking care of dying people were created in France. In 1842 Janine Gatnier crated a hospice in Lion (a city in France). A hospice was traditionally an inn or hotel for pilgrims or voy- agers. After the invention of Janine Gatnier, the term changed its original medieval meaning. The first hospices were for the severely and/or terminally ill people and were mostly created by religious nuns. No matter how big the initial desire to fight the diseases and to help the diseased was, the efficiency of first hospices was, understandably, very low (19). In 1950s are noteworthy for during this decade the drugs, non- steroid anti-infectious medicines etc. were created. More knowledge on cancer was accumulated etc. Moreover, medicine in general became less expensive and thus more accessible to wider public. Surprisingly at first patients were resistant towards the usage of drugs. No matter how well informed the patients were, they feared using them because believed that they would get addicted, would become totally senseless, would develop respiratory problems etc. These fears were maintained both by general public and numerous doctors. Many governments created obstacles for using this medication because of the same fears. Some counties allowed the use of this medication, but after a length and complicated burocratic procedure. A major event in the institutionalization of palliative care was the creation of St. Christopher’s Hospice in London in 1967 by Mrs. Sisley Sanders. Mrs. S. Sanders, undertook the responsibility to take care of dying people, which, she believed, included taking care of the family of the diseased, of consoling the family if it lost a member etc. Thanks to her dedication and her personal talent, Mrs. Sanders had a huge influence on the attitude towards the deadly ill people and towards the medical treatment they received a few decades ago. The indifferent, hopeless, single-sided attitude was replaced with value driven, comprehen- sive attitude towards the deadly ill people (20).

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Mrs. Sanders and her team at St. Christopher’s hospice did not develop a set of procedures that could be applied in all cases to all patients, however, the developed a general framework of concepts and activities which were exemplary for specialists from all over the globe. Mrs. Sanders, also proved by her own example, that one person, if dedicated and persistent, can change a great deal in the way business is done in a given sphere. As mentioned above, palliative care is not only a set of medical procedures, but a whole ideology which can, in fact, be used in all spheres of medicine. Issues of palliative care were discussed by UNO and the following points have been declared as decisive for palliative care. The palliative care: a. Manages the pain and other symptoms. b. Approves the life viewing the death as a normal occurrences c. Does not postpone death, does not bring death closer d. Addresses both spiritual and psychological problems of the patient e. Provides support to the relatives of the patient f. Improves the life quality of the diseased The social institutions for palliative care are, obviously, on different level of development in different countries. Some countries have very detailed law codes on palliative care, others do not. For example, the UK law on palliative care is so detailed that it lists the specialists that need to be involved in palliative care team. The palliative care as a very important medical service is in con- stant need for innovation and improvement. The medical research in this sphere, however, has additional difficulties as compared to other aspects of medical research. Palliative care is based on medical, psychological, social, religious etc. knowledge. Because it is very interdisciplinary and because it requires a huge personal investment, many ideas inherited from older generation of palliative care specialists are subjective and lack the necessary academic/scientific basis. This, however, does not disprove the possibility of a scientific palliative care discipline. Medical research in palliative care has additional complications, because most people who need palliative care are elderly citizens who suffer from their current health situation. This fact affects the overall

117 condition and function of other organs and thus complicates the medical research. Moreover, most patients who are not in extreme situation, prefer to live in their hoses, which makes almost impossible to include them in medical research projects, on the other hand, those patients who are in extreme situation, cannot handle extra pressure which the medical research necessarily involves. This also, causes complications for palliative care research. Medical research in palliative care can be further complicated for ethical (it is ethically unjustified to include socially/emotionally/physically vulnerable people in medical research), social (depending on social habits of the given society) etc. reasons. Because of these reasons, medical research in palliative care becomes a special research. To avoid the medical, ethical or social complications of this medical research it has been suggested to improve the communication among doctors. The improved communication will help doctors from all over the world be informed of any new achievement of palliative medical research and thus a) instantly apply the new knowledge, and b) avoid repeating the same medical research. An example of psychological research that is of major importance to palliative care is the examination of psychological stages a deadly ill person passes through. The research was conducted by Elisabeth Cyubler- Ross a psychiatrist from Switzerland. She Elisabeth separates 5 stages: K übl e r -Ross a. Denial – No, I cannot die! It cannot happen to me! b. Anger – Why me? There are so many people around, why me? c. Bidding – Oh God, I will not sin any more, if only you cure me, just cure me. d. Depression – The patient accepts that the death is inevitable and thinks about his/her sins, dreams s/he has not realized and the hopes s/he had. e. Acceptance – waits for his/her death with a peaceful mind (43).

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Once the palliative care specialist knows about these stages, it will be much easier for him/her to understand the patient and thus to help him/her overcome the diseases with greater ease. To sum up, it must be stated, that palliative care is an alternative to euthanasia. If the pro-euthanasia thinkers claim that once a person is deadly ill s/he must die, pro-palliative care thinkers think, that the deadly ill people should never be given artificial days nor be deprived of their natural (though may be miserable) days, but that these patient should be give more LIFE to the few days left for them to live. European Statistics on palliative care

in ain ly den - - - - gium many - - lands Ita Great Great Spa Nether Brit Swe Bel Ger

Population 10.1 81.9 57.4 15.6 40 8.8 57.1 (Millions) Hospices 1 64 3 16 1 69 219 Hospital depart- 49 50 0 2 23 ments Patients at 55 1 0 34 45 41 336 homes Nursing houses for 45 582 88 286 75 67 355 the elderly Daytime 2 9 0 0 0 13 248 services Exercises and Review Questions • Who was Mrs. Sisley Sanders? Google search her name and prepare a 1-2 minute presentation about her. • Who is Elisabeth Cyubler-Ross? Google search her name and prepare a 1-2 minute presentation about her. • What are the five psychological stages that deadly ill people have? • Name the principles of palliative care? Justify these principles from bioethical standpoint.

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SECTION 17

ARMENIAN MEDIEVAL PHILOSOPHY AND MEDICAL SCIENCE NAREK AS REMEDY

*** After completing this chapter you should be able to: a. understand what Narekatsi means by the term “health”, b. understand what Narekatsi means by the term “spiritual health”, c. understand why disease was associated sins, d. understand the philosophic foundations of curing with words and melody.

Health in Middle Ages From ancient times medication was considered to be a miracle, something that only magicians and those with supernatural powers could do. Hence a special reverence was conferred to those who mas- tered this unique trade. Health is a divine grace. The human creature is made of both flash and spirit thus the term health applies to two entities: to body and to spirit. The disease was considered to be a chaotic condition of body or spirit or both. Health was considered to be a harmony between the body 120 and the mind. If a person was healthy it was believed that all parts of his/her body were in a harmony and order. The opposite is also true: if a person was ill, it was believed that his/her spirit was rebelling against his body or vice versa his/her body was fighting against the spirit. The disease was associated with chaos. Thus a person could pass from the domain of order and harmony to the domain of disorder and chaos. It was also believed that there were two types of diseases: one physical and the other one spiritual (as against psychological). And because there were two diseases, both spiritual and physical means of curing were stressed in the past (64). Spiritual health was considered to be akin to common sense to the capacity of healthy judgment. Only those, who have proper capacity of judgment, who have clear mind and aspire to be present have common sense and are spiritually healthy. To be spiritually healthy means to be peaceful. Those who are spiritually healthy can differentiate the truth and falsehood. The spiritually healthy people are empathetic and support their fellows in need. Spiritually healthy people, accord- St. Gregor of Narek ing to Narekatsi are those with strong faith, they are free from negative passions. Being spiritually healthy means being humanly perfect that is as perfect as a human can be. Spiritual health is ensured through repentance, holiness, with strong faith, hope, love and other virtues. The Book of Narek The book known as Narek was written by Gregor of Narek a monastery in Eastern Armenia. Narek was written in 1001-1003 A.D. Gregor of Narek was a high rank priest who was both a very influential cleric as well as social/political figure of his time. Narek is an extensive prayer, composed of 95 parts and over 10000 lines none of which repeats the other. The prayer was highly valued in the middle ages and it was copied over and over numerous times. The Book of Narek, otherwise known as Book of Lamentation, is valued both for its artistic style and the important role it played among Armenians. Up to date thousands of

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Armenians maintain the belief that the book has a healing capacity and read it for the diseased (22). Narek was written for both glorifying the Almighty and for curing spiritual and physical diseases. Each of the 95 parts of the “Book of Lamentation” cures one disease. During the history specific lists have been created which specifically names the diseases each part (In Armenian Ban which means logos, word, and idea) cures. These lists also indicate the number of times each part needs to be read for observing its curing effect. In the introduction of the academic publication of Narek (Yerevan, 1985, pp. 158- 168) five similar lists of remedies are presented. A. Petrosyan, a scholar of Narek, adds another list from the manuscript # 8428 from the Matenadaran, the institute of Ancient manuscripts. This manuscript also indicates the number of times Narek needs to be read for attaining each of its curing effect. All 10000 lines are filled with love, the ultimate reverence towards the Almighty and with the consideration of human limitedness and sin- fulness. The Book starts with the following lines: The voice of a sighing heart, its sobs and mournful cries,1 I offer up to you, O Seer of Secrets,2 placing the fruits of my wavering mind 3 as a savory sacrifice on the fire of my grieving soul 4 to be delivered to you in the censer of my will.

Compassionate Lord, breathe in this offering and look more favorably on it than upon a more sumptuous sacrifice offered with rich smoke. Please find this simple string of words acceptable. Do not turn in disdain.

May this unsolicited gift reach you, this sacrifice of words from the deep mystery-filled chamber of my feelings, consumed in flames fueled by whatever grace I may have within me.7

As I pray, do not let these pleas annoy you, Almighty, 122 like the raised hands of Jacob, whose irreverence was rebuked by Isaiah, 8 nor let them seem like the impudence of Babylon criticized in the 72nd Psalm.

But let these words be acceptable as were the fragrant offerings in the tabernacle at Shiloh raised again by David on his return from captivity as the resting place for the ark of the covenant, a symbol for the restoration of my lost soul.

St. Gregory was a devoted son of the Armenian Church. He believed that the Armenian Church had a special mission and hoped that his book would help deliver that message: "as I was conceived and born in the womb of the Church... I now should address the great and immaculate queen. . . my glorious mother, so she may be known and proclaimed and the extent of her venerable glory might be told to the nations in the future." Having lost his mother when he was a child, he loved the Church like a mother: "This spiritual, heavenly mother of light cared for me as a son more than an earthly, breathing, physical mother could." People believed that Narek was a sacred book because of the majestic prayers it contained and believed that even touching the manuscript would cure them from diseases. People initiated long pilgrimages to see Narek, to have a touch of Narek or to pray on Narek. Few books have been as influential as the Narek. People had such a strong faith in Narek, that even the touch of Narek has produced positive results in terms of alleviating pain or curing. Numerous example of curing with Narek are registered historically. Many scholars think, that if a book similar to Narek was written by any European writer, it would gain universal acceptance even in the Middle Ages. The only reason Narek is not as widely known and read as works of Confutsius, Descartes, Hume etc. is because he has written in Armenian, a language that only a handful of people can read. The Narek is a nicely written book which makes everyone to analyze him/herself and to honestly evaluate his/her behavior and values. It leads the person to stand in front of God and in front of his horrible sins 123 against his/her body, his/her spirit, other individuals, the humankind and the Almighty (22). Narek is written in Grabar, the ancient Armenian and is a melodic prayer. It was believe that thanks to the fine style of its lines, it has gained even more power in leading people towards repentance, towards communion with God. Anyone who has read the Narek, will assure that it eventually brings peace, harmony and love onto the reader. Narekatsi himself St. Gregory was the son of Bishop Khosrov Andzevatsi. He was from a family of scholars at the Monastery of Narek, on the south- eastern shore of Lake Van, near his birthplace, home to the magnifi- cent, newly built 10th-century island cathedral of Aghtamar. He grew up in an atmosphere infused with ritual and Bible. Born in 951 shortly before the first millennium of Christianity, he followed his father and his uncle, the Abbot Anania, into Narek Monastery as did his brother Hovhannes, who later helped St. Gregory with the Book of Prayer. Ab- bot Anania was an original thinker and teacher, the founder and one of the pillars of Armenian mysticism. His father and uncle earned the ire of the church hierarchy for being independent thinkers. According to some commentators, these views may have implicated them in certain doctrinal disputes, which St. Gregory had to wrestle with throughout his life. Church tradition relates that, in his old age, he was called before a religious tribunal to defend his adherence to accepted doctrine. On this occasion he prepared a work, called the Root of Faith, once thought lost, but which appears to have been preserved in five doctrinal prayers of the Narek. The reverence for St. Gregory was already evident in his life time and his sainthood was recognized by his contemporaries. He is referred to as St. Gregory in the earliest extant manuscript of the Book of Pray- er, copied and illuminated by the scribe and miniaturist Gregor Skevratsi, containing a hagiography of St. Gregory written by St. Nerses Lambronatsi (1153-1198). During his own life, he was looked upon as a great teacher: "I was dubbed, 'Master,' which testifies against me. I was called, 'Teacher, teacher,’ In the manner of the saintly, his unworthiness was ever before him: "There is another ache in my heart, for they consider me to be something I am not." He was uncomfortable with this rever-

124 ence: "I was called by the highest names, but by my works I earned the worst of these descriptions" (18). Narekatsi searched the human perfectness in the perfect faith in God and suffered greatly for his ‘poor faith” in the Almighty: Look with mercy upon me in my doubts and perils, glorified Son of God, who alone are compassionate and will pardon, heal, save, protect, renew, restore, lift up, support, and create me again in blissful purity. Contents/ideas of Narek The idea of curing from diseases is mentioned in Narek numerous times. However, Narek and its curing methods are not comparable to today’s scientific curing methods, its results are not comparable to the results achieved by any contemporary medical institution. These methods are in two different spheres of culture and are used for two different types of diseases: one for spiritual diseases, the other for bodily ones. Thus these curing methods are better to consider complementary rather then contradictory. Narekatsi claims that he has written this text for curing the ills of body and soul: And may you make this book of mournful psalms be- gun in your name, Most High, into a life-giving salve for the sufferings of body and soul. (Prayer 3, E).

Narek offers mainly spiritual remedy. Its powers, as believed from early Middle Ages, was based on the power of the Word and Will of God. In all cases, when Narek suggests using a physical item for remedy it is a symbolic item, e.g. the Right Hand (22). Gregor of Narek relates sins and diseases. According to Narek, human diseases are a result of human sins. Sins force people to live with a life not naturally designed for human beings. For example, adultery, avarice etc. are forms of behavior that are not natural to human beings. Thus when a person sins, he/she starts to behave in a way for which the human body is not designed for and thus the body gets ill. Because both sins and diseases are caused by breaking the Divine law, they both can be overcome by repentance. The will, the decision to repent brings relief on the human being. But it does not happen all at once, the relief from pains comes during time and it may take long.

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In Narek first the sinful character of humans is depicted. Gregor of Narek undertakes the whole responsibility for all sins committed by all human beings at all times and thus demonstrates the need for curing the mankind. In order the mankind and individuals to be cured humans need to first conceive their sins. Once the sin is conceived the person needs to repent and later to suffer for sins as the Almighty decides. Narekatsi moves forward, in addition to depicting the vast majority of human sins and thus discovering the true nature of human psyche (I think no other writer or thinker has ever so well pictured the true nature of human psyche), he reveals the way for salvation. Narek is first of all a way for salvation. It is through this way of salvation, that the complexity and severity of his sins are revealed. And these sins include the lack of true faith, negative human passions, unhealthy social settings etc. On the other hand, Narek also pictures the positive aspects of human being: aspira- tion towards light, desire to have freedom, to clean and improve one’s own spirit. Narekatsi, being a Christian monk, based his book, the Narek on the Bible, because he believed no other book could be the bases for wisdom, genius, moral perfection and aesthetic joy, for fortification of will and attainment of eternal hope, for attainment of freedom and for clear- ing sins, for multiplying graces and freeing oneself from vices. Narekatsi claims that the non-objective, the word and will of God can be objectified, that is to get body and heaviness. Throughout his prayers he makes the same claim over and over again. All that happens in this word is simply objectification of divine word and will. There can also be non-physical, non-objective pain, that of the sin. When someone sins, he/she is hurt already and it eventually causes physical harm. Curing the physical damage of the body does not heal the person as a whole. Only the moral courage, the courage to repent and ask for forgiveness heals the person and cleans the person from sins. Thus, according to Narekatsi, diseases are nothing else but objectification of the non-objective, the will of God, the word of God, and to cure a disease, one needs not only physical means, but also non- objective, non physical remedies such as repentance.

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Curing with words/melody The attempts to cure someone with words that started thousands of years ago, now has changed into the practice of hypnosis and occultism, but Narek is neither a book of magic, nor a text were the luxurious words conceal the reality. In fact, the opposite is true, its words force the reader to believe that in order to live well one needs to live correctly, that in order to live well one needs to discover the true nature of humankind and take responsibility for making steps towards curing his/her spirit, towards God and towards a truly Holy reunion with the Universal Logos (64). You are able, compassionate God, to perform a miracle with your everlasting might saying, “Be healed of your soul’s torment,”1 or “May your sins be forgiven,”2 or “Go in peace. You are cleansed of sin.”3 And whatever I do not manage to say at that hour receive from me today in your love for mankind, O long- suffering, generous God, who gives life to all. The power of Narek as a remedy for diseases is explained also by the viewpoint of Word Remedy. The Word Remedy (Khoskabuzhutyun in Armenian) is the technique of curing the person with words. It was believe from ancient times that words exist by themselves, that words existed even before the physical objects and hence, their existence is more real. And because their existence is more real, then physical objects then they should be able to affect on human body and thus if they can affect on human Komitas body, they can also cure the human being if used correctly. In order the words to be powerful the contents must be well chosen and the person who uses the words must have great faith. In word remedy nothing but the Logos, the holy word and faith in God are used. The effectiveness of Narek is conditioned by the faith humans have. The stronger one’s faith the more productive his/her prayers will be, the wiser the person is, the more healing effects his/her words will have. Anything that is used when practicing word remedy, be it a 127 cross, an icon etc. have merely symbolic usage. One of the main sym- bols in Word Remedy is the right hand (The Holy Right –Surb Aj in Armenian) the right hand of the priest or of the Catholicos symbolized the right hand of Jesus Christ. In various Armenian dialects we have numerous phrases and expressions of interest from the standpoint of the issue of discussion. These expressions are “Let me carry your pain”, “Whatever evil is to happen to you, let it happen to me”, “My soul”, “My life” etc. These phrases have their value because they create corresponding internal psychological state in the individual. The great Armenian composer Komitas has very interesting statements about music and about healing with music. He separates two types of music: divine and human. The divine music is played in churches, for bringing the sinful spirits to repentance, and for convert- ing the sinful ideas into righteous ones. The human music is played in happy gatherings. If, Komitas thinks, the music can bring sinful spirits to righteousness or make sad people happy, why cannot it also push the disease away. Komitas was a bearer of the ancient view that all existence is composed of four elements: the soil, air, fire and water. Thus he, for example, he believed that a fours stringed musical instrument (k’nar- Harp) is preferable for medical purposes, because the human being also is composed of four elements. If I were to fill the basin of the sea with ink, and to measure out parchment the length and breadth of a field of many leagues and were to take all the reeds of the forests and woods and turn them into pens, I still would not be able to record even a fraction of my accumulated wrong doings. If I were to set the Cedars of Lebanon as a scale and to put Mount Ararat on one side and my iniquities on the other, it would not come close to balancing. Though deathly ill, he does not ask, "why me, why now?" He does not lament his plight. Rather he laments his unworthiness for God's grace and his own ingratitude and disobedience before God's good will. Shifting seamlessly between the individual and the universal he equates his ingratitude with that of humankind: "God spoke, but who listened? 128

He himself gave witness, but who believed?” He characterized his own unruliness in a colorful image, comparing himself to "a talking horse with a callous mouth, breaking my reins and shaking off my bit (22). It was a heavy burden, enough to break body and soul and to leave him feeling forlorn, yet never beyond God's care: This image of destruction reminds me of my misery, like a captain mourning his ship, chin in hand tears streaming down, viewing traces of the wreckage bobbing on the crest of the waves. My slain sanity sobs with pitiful grief. I did not stray from the truth in selecting these words to mourn the shattered ark of my intellect. For the Good Captain with his heavenly host took pity on the sea of humanity in just this way. At the end of the book, he expresses his doubt of reaching old age. This translates into anxiety that he will not have the strength or time to complete his work or his penance in order to realize his hope for deliver- ance and attain restoration to the light, properly prepared for death. Prayer 18, which has been adopted by the Armenian Church as part of its ritual of healing and prayer for the infirm, addresses the torment of terminal illness: And because the torments of my infirmities surpass even these examples, and like a spreading cancer have touched all the parts of my body, there is no salve as there was none for Israel, for my innumerable sores. Every part of my body from head to toe is unhealthy and beyond the help of physicians. But you, merciful, beneficent, blessed, long- suffering, immortal King, hear the prayers of my embattled heart for mercy, when I cry out to you, "Lord," in my time of need. Indeed at the beginning of the Armenian Divine Liturgy upon as- cending the altar, the deacon incants: "Why are you downcast, my soul?" St. Paul also addressed this sense of inadequacy: "likewise the Spirit helps us in our weakness; for we do not know how to pray as we ought, but the Spirit himself intercedes for us with sighs too deep for words, and he who searches the hearts of men knows what is in the mind of the Spirit, because the Spirit intercedes for the saints according to the will of God." In a similar way, St. Gregory offered "his testament of woes," on the one hand, fearful that his effort to translate the pure feelings of the heart into words would be inadequate, and on the other hand, filled with wonder at God's willingness to receive our prayers telling Him what He already knows more perfectly than we could ever express it. In the words of the Hymn of the Angels from the Armenian 129

Divine Liturgy: "You are surrounded by choirs of angels, yet you deign to accept this offering by mere humans." Still the impulse to speak and reconnect with God is overwhelming: "I long not so much for the gifts as for the Giver. I yearn not so much for the glory as the Glorified (Prayer 12b)." That impulse was urgent, since regret delayed could mean absolution denied: "The sighs of the heart that are not delivered now may not be accepted later (Pray- er 79d)."

Exercises and Review Questions a. Search the web and find the complete version of Book of Narek in English. b. Describe the theoretical bases of curing with words and melody c. Describe the theoretical and historical bases for linking the sin and the disease d. List 5 historical facts about the Book of Lamentation. e. Correspondence of human nature and melody according to Comitas. f. What is divine music according to Comitas? g. Why was the musical instrument harp considered suitable for curing purposes?

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SECTION 18

SOCIAL JUSTICE AND HEALTH POLICY

*** After completing this chapter, you should be able to: • understand the importance of medical research, • comprehend the stages of medical innovation, • comprehend some major problems of human experimentation, • Analyze research projects from ethical aspect.

Social Justice Justice is probably one of the most important terms of Ethic. Any major ethical theory provides an answer to the question: “What is justice?”

If some people can avoid metaethical questions regarding justice (such as What is justice? Why should people strive to be just? Etc.) no one can avoid practical issues related to justice. If I am a teacher of philosophy at YSMU and I need to organize an exam. How should I behave if one of my student cheats during a test, e.g. uses a hidden reference with the hope to get the highest score. What would be the just punishment? Should the student get a zero mark right away? Should the student be expelled from university? Should the student be give a second chance? What should I do, to restore the justice? (48).

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No need to prove, that medicine is one of central axis of human life. Everyone needs medical help now and then. But the reality is that many people cannot afford to pay for medicine, yet others have strong health and they need medical aid only once in every 10 years, lets say. Now, do we have a duty to make sure that everyone, if necessary, can get medical help? We obviously need to support those who are socially and financially disadvantaged. Now, once we agree on this statement, we need to ask the next question: “How are we supposed to do it?”. There have been a few suggested solutions for this issue: a. Mandatory health insurance - Mandatory health insurance policy solves many problems raising others. One of the issues caused by mandatory health insurance system is the issue of people who are unable to pay even for the insurance. What should we do for these people? Should they be taken for prison? Or should we simply provide these people with free medical aid. Another issue of mandatory health insurance is that some people may not need medical help for many years, while others might use it quite frequently, yet both pay the same amount for medical insurance. Now what should we do in this case? Should we charge more money from those who are in a worse health condition? Defi- nitely those who are in a worse health condition need and use more health service and in this case those who are in a better shape pay more then they probably should. b. Free medical service from the government – Free medical service from the Government is another suggestion to solve the issue of accessibility of medical aid. Free medical service is implemented in two forms: full coverage of medical service costs by the Government and selective coverage of medical service costs. As well known few countries are able to provide full coverage of medical service costs for its citizens, thus it is more pragmatic to discuss the second version, the selective coverage of medical service costs. This however, raises very important issues, such as the following: “What diseases should be cured by the Government?”, “Who should be the primary beneficiaries of Government support?”, “What mini-

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mal quality of medical service should be provided free of charge by the Government?” Etc.

Importance of Medical Research Medicine is not an exact science in the way that mathematics and physics are. It does have many general principles that are valid most of the time, but every patient is different and what is an effective treatment for 90% of the population may not work for the other 10%. Thus, medicine is inherently experimental. Even the most widely accepted treatments need to be monitored and evaluated to determine whether they are effective for specific patients and, for that matter, for patients in general. This is one of the functions of medical research. Another, perhaps, better known, function is the development of new treatments, especially drugs, medical devices and surgical techniques. Great progress has been made in this area over the past 50 years and today there is more medical research underway than ever before. Nev- ertheless, there are still many unanswered questions about the function- ing of the human body, the causes of diseases (both familiar and novel ones) and the best ways to prevent or cure them. Medical research is the only means of answering these questions (41). In addition to seeking a better understanding of human physiology, medical research investigates a wide variety of other factors in human health, including patterns of disease (epidemiology), the organization, funding and delivery of healthcare (health systems research), social and cultural aspects of health (medical sociology and anthropology), law (legal medicine) and ethics (medical ethics). The importance of these types of research is being increasingly recognized by funding agencies, many of which have specific programs for non-physiological medical research.

Research in medical practice All physicians make use of the results of medical research in their clinical practice. To maintain their competence, physicians must keep up with the current research in their area of practice through lifelong learning. Even if they do not engage in research themselves, physicians must know how to interpret the results of research and apply them to their patients. Thus, a basic familiarity with research methods is essential for competent medical practice. The best way to gain this familiari- 133 ty is to take part in a research project, either as a medical student or following qualification.

The most common method of research for practicing physicians is the clinical trial. Before a new drug can be approved by government- mandated regulatory authorities, it must undergo extensive testing for safety and efficacy. The process begins with laboratory studies followed by testing on animals. If this proves promising, the four steps, or phases, of clinical research are as follows:

• Phase one of the research, usually conducted on a relatively small number of healthy volunteers, who are often paid for their participation, is intended to determine what dosage of the drug is required to produce a response in the human body, how the body processes the drug and whether the drug produces tox- ic or harmful effects.

• Phase two of the research is conducted on a group of patients who have the disease that the drug is intended to treat. Its goals are to determine whether the drug has any beneficial effect on the disease and has any harmful side effects.

• Phase three of the research is the clinical trial, in which the drug is administered to a large number of patients and compared to another drug, if there is one for the condition in question, and/or to a placebo. Where possible, such trials are ‘dou- ble-blinded’, i.e., neither research subjects nor their physicians know who is receiving which drug or placebo.

• Phase four of the research takes place after the drug is licensed and marketed. For the first few years, a new drug is monitored for side effects that did not show up in the earlier phases. Addi- tionally, the pharmaceutical company is usually interested in how well the drug is being received by physicians who prescribe it and patients who take it.

The rapid increase in recent years in the number of ongoing trials has required finding and enrolling ever-larger numbers of patients to meet the statistical requirements of the trials. Those in charge of the trials, whether independent physicians or pharmaceutical companies, 134 now rely on many other physicians, often in different countries, to en- roll patients as research subjects.

Although such participation in research is valuable experience for physicians, there are potential problems that must be recognized and avoided. In the first place, the physician’s role in the physician-patient relationship is different from the researcher’s role in the researcher- research subject relationship, even if the physician and the researcher are the same person. The physician’s primary responsibility is the health and well-being of the patient, whereas the researcher’s primary responsibility is the generation of knowledge, which may or may not contribute to the research subject’s health and well-being. Thus, there is a potential for conflict between the two roles. When this occurs, the physician role must take precedence over the researcher’s. What this means in practice will be evident below. Another potential problem in combining these two roles is conflict of interest. Medical research is a well-funded enterprise, and physicians are sometimes offered considerable rewards for participating. These can include cash payments for enrolling research subjects, equipment such as computers to transmit the research data, invitations to conferences to discuss the research findings, and co-authorship of publications on the results of the research. The physician’s interest in obtaining these benefits can sometimes conflict with the duty to provide the patient with the best available treatment. It can also conflict with the right of the patient to receive all the necessary information to make a full informed decision whether or not to participate in a research study. These potential problems can be overcome. The ethical values of the physician – compassion, competence, autonomy – apply to the medical researcher as well. So, there is no inherent conflict between the two roles. As long as physicians understand and follow the basic rules of research ethics, they should have no difficulty participating in research as an integral component of their clinical practice.

Ethical Requirements The basic principles of research ethics are well established. It was not always so, however. Many prominent medical researchers in the 19th and 20th centuries conducted experiments on patients without their consent and with little if any concern for the patients’ well-being. Alt-

135 hough there were some statements of research ethics dating from the early 20th century, they did not prevent physicians in Nazi Germany and elsewhere from performing research on subjects that clearly violated fundamental human rights. Following World War Two, some of these physicians were tried and convicted by special tribunal at Nuremberg, Germany. The basis of the judgment is known as the Nuremberg Code, which has served as one of the foundational documents of modern research ethics. Among the ten principles of this Code is the requirement of voluntary consent if a patient is to serve as a research subject (74).

The World Medical Association was established in 1947, the same year when the Nuremberg Code was set forth. Conscious of the violations of medical ethics before and during World War Two, the Found- ers of WMA immediately took steps to ensure that physicians would at least be aware of their ethical obligations. In 1954, after several years of study, the WMA adopted a set of Principles for Those in Research and Experimentation. This document was revised and adopted as the Declaration of Helsinki (DoH) in 1964. The DoH is a concise summary of research ethics. Other, much more detailed documents have been produced in recent years on research ethics. Below are presented some major issues that all international documents on human experimentation agree on.

Ethics Review Committee Approval The DoH stipulates that every proposal for medical research on human subjects must be reviewed and approved by an independent ethics committee before it can proceed. In order to obtain approval, the researchers must explain the purpose and methodology of the project; demonstrate how research subjects will be recruited, how their consent will be obtained and how their privacy will be protected; specify how the project is being funded; and disclose any potential conflicts of interest on the part of the researchers. The ethics committee may approve the project as presented, require changes before it can start, or refuse approval altogether. Many committees have a further role of monitoring projects that are underway to ensure that the researchers fulfill their obligations and they can if necessary stop a project because of serious unexpected adverse events.

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The reason why ethics committee approval of a project is required is that neither researchers nor research subjects are always knowledgeable and objective enough to determine whether a project is scientifically and ethically appropriate. Researchers need to demonstrate to an impar- tial expert committee that the project is worthwhile, that they are competent to conduct it, and that potential research subjects will be protected against harm to the greatest extent possible (75). Scientific Merit According to DoH, human subjects must be justifiable on scientific grounds. This requirement is meant to eliminate projects that are unlikely to succeed, for example, because they are methodologically inadequate, or that, even if successful, will likely produce trivial results. If patients are being asked to participate in a research project, even where risk of harm is minimal, there should be an expectation that important scientific knowledge will be the result. To ensure scientific merit, DoH requires that the project should be based on a thorough knowledge of the literature on the topic and on previous laboratory and, where appropriate, animal research that gives good reason to expect that the proposed intervention will be efficacious in human beings. All research on animals must conform to ethical guidelines that minimize the number of animals used and prevent un- necessary pain (81).

Social Value Medical research must contribute to the well-being of society in general. It used to be widely agreed that advances in scientific knowledge were valuable in themselves and needed no further justification. However, as resources available for medical research are increasingly inadequate, social value has emerged as an important criterion for judging whether a project should be funded. The importance of the project’s objective, understood as both scientific and social importance, should outweigh the risks and burdens to research subjects. Furthermore, the populations in which the research is carried out should benefit from the results of the research. This is especially important in countries where there is potential for unfair treatment of research subjects who undergo the risks and discomfort of research while the drugs developed as a result of the research only benefit patients elsewhere.

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Exercises and Review Questions • Read the Declaration of Helsinki and make a presentation • Research the Internet and find other international documents on human experimentation. • Which paragraphs in DoH regard the Informed Consent? • Which paragraph of DoH is about risks and potential benefits of DoH?

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SECTION 19

MEDICAL CASES AND PRACTICAL SOLUTIONS

*** Oscar Pistorius Case Oscar Pistorius wanted to be the first amputee runner in the Olympic Games 2008. He has got no legs, but special prosthetics for doing sports. He took part in the Paralympics quite successfully and calls himself to be the “fastest man without legs”. His marks are even that good that he would have won gold medal in equivalent women’s races at the 2004 Athens Olympics. So he decided to apply to get part in the Olympics in Beijing. The International Olympic Committee was worried about if the technology of his prosthetics may give him an unfair advantage over sprinters using their natural legs. So they did some studies abut Pistorius’ j-shaped blades made of carbon fiber and the way he runs in comparison to “healthy” athletes. So the question is: Is Pistorius disabled or too-abled? Are this prosthetics the beginning of “techno-doping”?

Treatment without consent Mrs. E.D. is a 69 year old retired bank manager. She has been suffering from poorly controlled diabetes for the last 18 years. For the last 6 months she has needed hemodialysis twice a week for end-stage renal disease. Three days ago, she was hospitalized because of an infected non-healing would at the amputated stump of her left leg. Two days 139 later gangrene set in. Following a meeting of her diabetologist, infectious disease specialist, surgeon, and family it was decided to amputate. Her eldest son, a physician, agreed to the amputation but announced that no one should tell her about it. She would only be told that the wound would be “surgically cleaned”. Last year when the foot was to be amputated, Mrs. E. D. refused to five her consent. They did it without her consent and after her initial anger for a few days she appeared to understand the need and no longer blamed them. Her son anticipated the same reaction and feels informing her will only add more stress. Her husband and other children agree to the plan.

HIV Patients Mrs. W.L., a 29 year old married woman, and her husband are patient at the clinic. W.L. visits the clinic looking very sad. She lost her two children in the last three years, all before the age of three years, due to diarrhea and severe febrile illnesses. During the illness of her last baby, the doctor attending the baby counseled that the baby and she undergo HIV tests. Both tests came out positive and were confirmed on further testing. She believes that her husband infected her. She has heard rumors that he was a womanizer, but he denied this when she confronted him. Now, the husband, a prosperous businessman, is continuously insisting that she conceive again so that he may gain recognition among his friends and the child born can inherit his wealth. He further warns that if this does not happen within a year, he will divorce her and marry a younger woman. He is not aware of her HIV status nor des he know his. The wife is afraid of revealing her HIV status for fear of a divorce.

Warning the friend? A 45 year old rich, handsome, sociable and elegant man, a member of the jetset society, had an amorous relationship with an equally elegant and beautiful 35-year old woman. Due to some bouts of jealousy on the part of the man (possibly of morbid dimensions), the young woman decided to put an end to the relationship. Following this, the man visited a psychiatrist, whom he had been seeing for some time, informed him that he was carrying a gun and that his next visit would be to his ex-girl-friend because he intended to kill her. He added that this information was confidential from patient to doctor and that any breach in confidentiality would not remain unnoticed. They psychia- 140 trist decided that a breach of confidentiality was necessary in this case and informed the lady and the police. When asked by the police, the man denied that he had bad intentions. A heated discussion among professionals followed, which was re-fuelled by the fact that this man eventually managed to kill his ex-friend with the very gun he carried when he visited the psychiatrist’s office.

The Politician A sixty-eight year old powerful politician was affected with Lou Gehrig’s disease (Amyotrophic Lateral Sclerosis) and given no more than one year of life. She prohibited her doctor to ever mention her condition eve to her husband or her family because of the sensitive political situation that such a revelation might entail or to seek further consultations. As her condition worsened, pressures mount on her doctor to refer her to another physician or to hospitalize her. Following the expressed directions of his patent he refused, but her family insists on consultation and possible hospitalization.

Conflict of interests A seventy-six year old very wealthy woman is affected with mild dementia. Her children call on her doctor complaining of her spending habits of giving liberally to members of a church cult, whom they think, are scheming to alight her of her wealth. They are worried about their rights to her inheritance and request from the doctor to declare her in- competent to manage her own affairs. The doctor dutifully advises his patient about the visit from her children and told her that he did not think that a psychiatric consultation was in order. The doctor himself was a member of the same church cult.

Conflict of Interests A fifty year old psychiatrist hires a patient to clean her apartment. At the same time she is treating the patient for phobias with hypnosis after returning home in the evenings. The arrangement for her cleaning work was intended to provide a kind of “payment’ for the treatment she could not afford otherwise.

The bus driver A 46 year old man, married and father of three children, is a bus driver on an inter-urban line on difficult roads across the mountains. In a consultation with a doctor, his main complain is that he has started to 141 experience episodes of acute tachycardia during the past five months, following the death of his mother. It happened first when he was in the street, where he thought that he was taking leave of his senses and was about to die. In the emergency room of the hospital to which he was rushed he was diagnosed as having a heart that was in a good shape, but owing to his stress, he was advised to take a holiday. Upon return from his vacation he began to suffer the same episodes especially when he was driving across the mountains. He also began to believe that his driving might become careless and cause him to drop into the ravine. He insisted that this was exclusively a heart disease, refusing to consider that he was suffering from any kind of panic disorder which might be complicated by agoraphobia. Refusing to accept any psychotropic medication or psychotherapy, he demanded treatment by a cardiologist. He asserted that he would refuse to take “the same kind of medication as his mother”, who had been treated for years as a person with schizo- phrenia. At the same time he continued working on his arduous bus route, since he had contracted debts with he had to repay.

Minors A child aged 8 was referred to a mental health hospital by the social worker for family affairs who reported behavior disorders. The child and his brother are caught in the midst of severe divorce disputes between their parents, and are in temporary custody of their father. In the first diagnostic session this boy’s behavior could be described as hos- tile; he was furious and his answers were laconic. The moment the meeting was over, the father entered the room, and in front of his son demanded to see what was written in his file. He said, “According to the patients’ Rights Law I’m entitled to see the notes you write in my son’s file”. He added that he deserved to know what his son thought about his mother and about him. It seems that the father perceived this son as being more attached to the mother, and as betraying him by loving his mother too. This child was probably aware of his father’s intru- siveness and therefore he refused to cooperate in the psychiatric examination. Also, it was clear that the child was afraid to cooperate and reveal his feelings and thoughts, as his experience taught him that.

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Trouble in palliative care unit In France, a 58 year old patient suffering from and ENT-Cancer (ENT: Ear-Nose-Throat) has been accepted in a palliative care unit to end his life in security. His family wasn’t able to keep him at home. Usually, nurses are scared by an ENT-cancer patient, because he is liable to develop a metastasis in his throat. It was actually the case for this man. A metastasis was growing in his throat. Even if he couldn’t see himself, he knew that it was growing in his throat. He was feeling it slowly developed. He risks seeing his carotid exploded under the pressure of the metastasis. That sound as a bomb for the patient, and also for nurses who dread the last moment. This case is particularly frightening for nurses because they are closely confronted with the decision of giving death to the patient. Nurses find this kind of situation especially horrible. According to nurses, the patient’s pain is to assist consciously to his death, because he sees the bleeding when his carotid is exploding. “He is bleeding to death” said they. In order to avoid him to see all of his blood, nurse injects a poison “to make him sleep”. The syringe is prepared and it is placed near the patient’s bed. So the nurse’s gesture is speed, and that sound as an execution so much so few nurses feel guilty when the patient won’t wake up after the injection.

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APPENDIX Sample Test

1. What is principalism? a. It is the method of moral decision making, during which the individual makes decisions based on his/her core moral values and not on possible consequences of his/her actions b. It is the branch of anatomy that studies the principles of healthy lifestyle and the things that can damage the good health c. It is a synonym of “Bioethics”, that is the science of “Bioethics” which is sometimes called principalism. d. It is the branch of Bioethics that studies the principal issues of genetic engineering

2. Who is the author of the book: “Bioethics: A bridge to future?” a. Van Ranseller Potter b. Albert Schweitzer c. David the Invincible d. Plato

3. Which are the two ways of decision making? a. intuition and imitation b. correct and not really correct c. rational and traditional d. rational and non-rational

4. Who is the author of the principle of “Golden Mean”? a. Mahatma Gandhi b. Van Ranseller Potter c. Aristotle d. Albert Schweitzer

5. What is unvoluntary hospitalization? a. it is the act of punishing a person for his antisocial behavior b. it is the act of taking a person to hospital against his will c. it is the act of forcing the government to build hospitals in all re- gions of the country d. it is the act of punishing people who intended to commit suicide

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6. What is “informed consent”? a. it is the patient’s relatives’ and family members’ agreement to op- erate on the patient b. it is the doctor’s right to conduct the medical treatment according to the best of his/her knowledge c. it is the doctor’s agreement to take care of the patient d. it is the patient’s informed agreement to undertake the special medical treatment as suggested by a doctor

7. On which value/principle is the Paratsels model of medicine built? a. behave in a way that you would like everyone else to behave b. equality: pay equal attention to every patient c. do good: have the internal drive to help people d. egocentric: make all patients respect the doctor and follow his instructions.

8. With what sciences is NOT Bioethics related? a. astrophysics b. biology c. law d. psychology

9. Whose word are these: “Do I have the right to pick all the fruit that I can reach for?” a. Schweitzer b. Aristotel c. Plato d. Kant

10. When did David the Invinchable write his main book: “Defini- tions of Philosophy”? a. 800 years ago b. 1500 years ago c. 1200 years ago d. 1150 years ago e. 920 years ago

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11. Who is Mkhitar Gosh? a. a modern specialist of politics b. a scientist from the Reneissance c. c. an ancient Philosopher

12. In the work of which author we can find fragment of involuntary abortion and sterilization? a. T. Williams b. Lukas Barfuss c.Aghasi Aivazyan d. Federico Garsia Lorka

13. Why is there a need for medical ethics? a. medicine is a unique profession, the doctors works with people b. general ethics gives a lot of knowledge, but does not help to make specific decisions in medical practice c. it helps to discover solutions for moral problems in practice d. it is one of the ways to respect A. Shveitzer, one of the greatest men of 20th century

14. Who are the 2 founders of utilitarism? 1. Jeremy Bentham 2. Immanuil Kant 3. Hume 4. John Stuart Mill

15. Which of the following ideas belongs to I. Kant? 1. Categorical imperative 2. Virtue is knolege 3. Moral autonomy 4. Discursive ethics

16. What are types of doctor patient relationships? 1. technical 2. contract based 3. paternalistic 4. fraternalistic 146

17. Which ethical theories have influensed Bioethics? 1. Deontology 2. Utilitarianizm 3. Hedonizm 4. Pragmatizm

18.What are non – rational approaches for making moral decisions? 5. 1. intuition 6. 2. rights and law 7. 3. consequentalism 8. 4. obedience 9. 5. tradition

19.Which armenian thinkers have written about medical ethics? 10. 1. Shnorhali Nerses 11. 2. David the Invincible 12. 3. Lastivertsi 13. 4. Amasiatsi 14. 5. Mkhitar Gosh

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Self-Work Topics Resources about these topics can be easily found from the Internet and manuals of Bioethics. Further recommendations about possible sources can be attained from instructors.

Theoretical Ethics 1. What is Ethics - Bernard E. Rollin, pp 31-66 2. The Sophists and Socrates – Alasdair Mac Intyre pp. 14-26 3. British Enlightenment – Alasdair MacIntyre pp. 157-178 4. French Enlightenment – Alasdair MacIntyre pp. 178-190 5. Moral teaching of Immanuel Kant - Alasdair MacIntyre pp. 190-199 6. Utilitarians, Reformers and Idealists – Alasdair MacIntyre pp. 227-249

Classical Bioethical issues 1. History and future of bioethics - Albert R. Jensen, from Rehmann-Sutter Ch. Etc. pp. 13-21 2. The need for ethical evaluation in biomedicine and biopolitics- Diatmar Mieth, from Rehmann-Sutter Ch. Etc. pp. 21-45. 3. The value free science – Bernard E. Rolin, pp. 11-31.

Contemporary Issues of Bioethics 1. Ethics in bioscience companies - David L. Finegold etc. Bioindustry Ethics 4-17 2. Moral aspects of genetic engineering, Bernard E. Rollin, pp. 129-155 3. Moral aspects of cloning, xenotranplantation and stem cells, Bernard E. Rollin, pp. 185-215 4. Ethics and Research on Human Beings, Bernard E. Rollin, pp. 66-99 5. Moral aspects of animal research – Bernard E. Rollin, pp. 99- 129 6. Sexual contact with patients – Bernard Lo, pp. 236-243. 7. Health care reforms – Bernard Lo, pp. 363-369. 8. Life sustaining practices – Bernard Lo, pp. 201-207.

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9. Ethics committees and case consultants – Bernard Lo, pp. 146- 158.

Other open topics 1. Physician’s duties and responsibilities 2. Physician and society, physician and health activity 3. Eco-bioethics 4. Dental ethics 5. Environmental ethics 6. Ethics and law 7. Ethics and religion 8. Ethics and sciences 9. Medical ethics 10. Meta-ethics 11. Pharmacethics 12. Philosophical ethics 13. Scientiic ethics 14. Technological ethics 15. Veterinary ethics

Sources for individual work topics • Alasdair Mac Intryre, A Short History of Ethics, Macmillan Publishing Company , 1966 • Bernard Lo, Resolving Ethical Dilemmans, Williams & Wil- kins , 1995 • Bernard E. Rolin, Science and Ethics, Cambridge University Press , 2006 • David L. Finegold etc. Bioindustry Ethics, • Rehmann-Sutter, Ch., Duwell M. Bioethics in Cultural Con- texts, Springer, 2006

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INTERNATIONAL DOCUMENTS ON MEDICAL ETHICS

OATH OF HIPPOCRATES CERCA 400 B.C.

Introductory Note HIPPOCRATES, the celebrated Greek physician, was a contemporary of the historian Herodotus. He was born on the island of Cos between 470 and 460 B.C., and belonged to the family that claimed de- scent from the mythical Æsculapius, son of Apollo. There was already a long medical tradition in Greece before his day, and this he is supposed to have inherited chiefly through his predecessor Herodicus; and he enlarged his education by extensive travel. He is said, though the evidence is unsatisfactory, to have taken part in the efforts to check the great plague which devastated Athens at the beginning of the Pelopon- nesian war. He died at Larissa between 380 and 360 B.C. The works attributed to Hippocrates are the earliest extant Greek medical writings, but very many of them are certainly not his. Some five or six, however, are generally granted to be genuine, and among these is the famous "Oath." This interesting document shows that in his time physicians were already organized into a corporation or guild, with regulations for the training of disciples, and with an esprit de corps and a professional ideal which, with slight exceptions, can hardly yet be regarded as out of date. One saying occurring in the words of Hippocrates has achieved universal currency, though few who quote it to-day are aware that it origi- nally referred to the art of the physician. It is the first of his "Apho- risms": "Life is short and the Art long; the occasion fleeting; experience fallacious, and judgment difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the at- tendants, and externals cooperate."

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THE OATH OF HIPPOCRATES

I SWEAR by Apollo the physician and Æsculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation — to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art. I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further, from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional service, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times. But should I trespass and violate this Oath, may the reverse be my lot.

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THE WORLD MEDICAL ASSOCIATION DECLARATION OF GENEVA (1948) PHYSICIAN'S OATH

Introductory Note Adopted by the General Assembly of the World Medical Associa- tion, Geneva, Switzerland, in September 1948 and amended by the 22nd World Medical Assembly, Sydney, Australia, in August 1968. The World Medical Association is an association of national medical associations. This oath seems to be a response to the atrocities committed by doctors in Nazi Germany. Notably, this oath requires the physician to "not use [his] medical knowledge contrary to the laws of humanity."

Physician's Oath At the time of being admitted as a member of the medical profession: I solemnly pledge myself to consecrate my life to the service of humanity; I will give to my teachers the respect and gratitude which is their due; I will practice my profession with conscience and dignity; the health of my patient will be my first consideration; I will maintain by all the means in my power, the honor and the noble traditions of the medical profession; my colleagues will be my brothers; I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient; I will maintain the utmost respect for human life from the time of conception, even under threat; I will not use my medical knowledge contrary to the laws of humanity; I make these promises solemnly, freely and upon my honor.

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UNIVERSAL DECLARATION ON BIOETHICS AND HU- MAN RIGHTS (WITH ABBREVIATIONS)

19 October 2005, The General Conference, Conscious of the unique capacity of human beings to reflect upon their own existence and on their environment, to perceive injustice, to avoid danger, to assume responsibility, to seek cooperation and to ex- hibit the moral sense that gives expression to ethical principles,

Reflecting on the rapid developments in science and technology, which increasingly affect our understanding of life and life itself, resulting in a strong demand for a global response to the ethical implications of such developments,

Recognizing that ethical issues raised by the rapid advances in science and their technological applications should be examined with due respect to the dignity of the human person and universal respect for, and observance of, human rights and fundamental freedoms,

Resolving that it is necessary and timely for the international community to state universal principles that will provide a foundation for humanity’s response to the ever-increasing dilemmas and controversies that science and technology present for humankind and for the environment,

Recognizing that this Declaration is to be understood in a manner consistent with domestic and international law in conformity with human rights law,

Recalling the Constitution of UNESCO adopted on 16 November 1945,

Considering UNESCO’s role in identifying universal principles based on shared ethical values to guide scientific and technological development and social transformation in order to identify emerging challenges in science and technology taking into account the responsibility of the present generations towards future generations, and that ques-

153 tions of bioethics, which necessarily have an international dimension, should be treated as a whole, drawing on the principles already stated in the Universal Declaration on the Human Genome and Human Rights and the International Declaration on Human Genetic Data and taking account not only of the current scientific context but also of future developments,

Aware that human beings are an integral part of the biosphere, with an important role in protecting one another and other forms of life, in particular animals,

Recognizing that, based on the freedom of science and research, scientific and technological developments have been and can be of great benefit to humankind in increasing, inter alia, life expectancy and improving the quality of life, and emphasizing that such developments should always seek to promote the welfare of individuals, families, groups or communities and humankind as a whole in the recognition of the dignity of the human person and universal respect for, and observance of, human rights and fundamental freedoms,

Recognizing that health does not depend solely on scientific and technological research developments but also on psychosocial and cultural factors,

Bearing in mind that cultural diversity, as a source of exchange, innovation and creativity, is necessary to humankind and, in this sense, is the common heritage of humanity, but emphasizing that it may not be invoked at the expense of human rights and fundamental freedoms,

Convinced that moral sensitivity and ethical reflection should be an integral part of the process of scientific and technological developments and that bioethics should play a predominant role in the choices that need to be made concerning issues arising from such developments,

Considering the desirability of developing new approaches to social responsibility to ensure that progress in science and technology contributes to justice, equity and to the interest of humanity,

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Stressing the need to reinforce international cooperation in the field of bioethics, taking into account, in particular, the special needs of developing countries, indigenous communities and vulnerable populations,

Considering that all human beings, without distinction, should benefit from the same high ethical standards in medicine and life science research, Proclaims the principles that follow and adopts the present Declara- tion. General provisions Article 1 – Scope 1. This Declaration addresses ethical issues related to medicine, life sciences and associated technologies as applied to human beings, taking into account their social, legal and environmental dimensions.

2. This Declaration is addressed to States. As appropriate and relevant, it also provides guidance to decisions or practices of individuals, groups, communities, institutions and corporations, public and private. Article 2 – Aims The aims of this Declaration are: (a) to provide a universal framework of principles and procedures to guide States in the formulation of their legislation, policies or other instruments in the field of bioethics; (b) to guide the actions of individuals, groups, communities, institutions and corporations, public and private; (c) to promote respect for human dignity and protect human rights, by ensuring respect for the life of human beings, and fundamental freedoms, consistent with international human rights law; (d) to recognize the importance of freedom of scientific research and the benefits derived from scientific and technological developments, while stressing the need for such research and developments to occur within the framework of ethical principles set out in this Declaration and to respect human dignity, human rights and fundamental freedoms; (e) to foster multidisciplinary and pluralistic dialogue about bioethical issues between all stakeholders and within society as a whole; (f) to promote equitable access to medical, scientific and technological developments as well as the greatest possible flow and the rapid sharing

155 of knowledge concerning those developments and the sharing of benefits, with particular attention to the needs of developing countries; (g) to safeguard and promote the interests of the present and future generations; (h) to underline the importance of biodiversity and its conservation as a common concern of humankind. Principles Within the scope of this Declaration, in decisions or practices taken or carried out by those to whom it is addressed, the following principles are to be respected. Article 3 – Human dignity and human rights 1. Human dignity, human rights and fundamental freedoms are to be fully respected. 2. The interests and welfare of the individual should have priority over the sole interest of science or society. Article 4 – Benefit and harm In applying and advancing scientific knowledge, medical practice and associated technologies, direct and indirect benefits to patients, research participants and other affected individuals should be maximized and any possible harm to such individuals should be minimized. Article 5 – Autonomy and individual responsibility The autonomy of persons to make decisions, while taking responsibility for those decisions and respecting the autonomy of others, is to be respected. For persons who are not capable of exercising autonomy, special measures are to be taken to protect their rights and interests. Article 6 – Consent 1. Any preventive, diagnostic and therapeutic medical intervention is only to be carried out with the prior, free and informed consent of the person concerned, based on adequate information. The consent should, where appropriate, be express and may be withdrawn by the person concerned at any time and for any reason without disadvantage or prejudice. 2. Scientific research should only be carried out with the prior, free, express and informed consent of the person concerned. The information should be adequate, provided in a comprehensible form and should include modalities for withdrawal of consent. Consent may be withdrawn by the person concerned at any time and for any reason without any

156 disadvantage or prejudice. Exceptions to this principle should be made only in accordance with ethical and legal standards adopted by States, consistent with the principles and provisions set out in this Declaration, in particular in Article 27, and international human rights law. Article 7 – Persons without the capacity to consent In accordance with domestic law, special protection is to be given to persons who do not have the capacity to consent: (a) authorization for research and medical practice should be obtained in accordance with the best interest of the person concerned and in accordance with domestic law. However, the person concerned should be involved to the greatest extent possible in the decision-making process of consent, as well as that of withdrawing consent; (b) research should only be carried out for his or her direct health benefit, subject to the authorization and the protective conditions prescribed by law, and if there is no research alternative of comparable effectiveness with research participants able to consent. Research which does not have potential direct health benefit should only be undertaken by way of exception, with the utmost restraint, exposing the person only to a minimal risk and minimal burden and, if the research is expected to contribute to the health benefit of other persons in the same category, subject to the conditions prescribed by law and compatible with the protection of the individual’s human rights. Refusal of such persons to take part in research should be respected. Article 8 – Respect for human vulnerability and personal integrity In applying and advancing scientific knowledge, medical practice and associated technologies, human vulnerability should be taken into account. Individuals and groups of special vulnerability should be protected and the personal integrity of such individuals respected. Article 9 – Privacy and confidentiality The privacy of the persons concerned and the confidentiality of their personal information should be respected. To the greatest extent possible, such information should not be used or disclosed for purposes other than those for which it was collected or consented to, consistent with international law, in particular international human rights law. Article 10 – Equality, justice and equity The fundamental equality of all human beings in dignity and rights is to be respected so that they are treated justly and equitably.

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Article 12 – Respect for cultural diversity and pluralism The importance of cultural diversity and pluralism should be given due regard. However, such considerations are not to be invoked to infringe upon human dignity, human rights and fundamental freedoms, nor upon the principles set out in this Declaration, nor to limit their scope. Article 14 – Social responsibility and health 1. The promotion of health and social development for their people is a central purpose of governments that all sectors of society share. 2. Taking into account that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition, progress in science and technology should advance: (a) access to quality health care and essential medicines, especially for the health of women and children, because health is essential to life itself and must be considered to be a social and human good; b) access to adequate nutrition and water; (c) improvement of living conditions and the environment; d) elimination of the marginalization and the exclusion of persons on the basis of any grounds; (e) reduction of poverty and illiteracy. Article 15 – Sharing of benefits 1. Benefits resulting from any scientific research and its applications should be shared with society as a whole and within the international community, in particular with developing countries. In giving effect to this principle, benefits may take any of the following forms: (a) special and sustainable assistance to, and acknowledgement of, the persons and groups that have taken part in the research; (b) access to quality health care; (c) provision of new diagnostic and therapeutic modalities or products stemming from research; (d) support for health services; (e) access to scientific and technological knowledge; (f) capacity-building facilities for research purposes; (g) other forms of benefit consistent with the principles set out in this Declaration. 2. Benefits should not constitute improper inducements to participate in research.

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Article 16 – Protecting future generations The impact of life sciences on future generations, including on their genetic constitution, should be given due regard. Article 17 – Protection of the environment, the biosphere and biodiversity Due regard is to be given to the interconnection between human beings and other forms of life, to the importance of appropriate access and uti- lization of biological and genetic resources, to respect for traditional knowledge and to the role of human beings in the protection of the environment, the biosphere and biodiversity. Application of the principles Article 18 – Decision-making and addressing bioethical issues 1. Professionalism, honesty, integrity and transparency in decision- making should be promoted, in particular declarations of all conflicts of interest and appropriate sharing of knowledge. Every endeavour should be made to use the best available scientific knowledge and methodology in addressing and periodically reviewing bioethical issues. 2. Persons and professionals concerned and society as a whole should be engaged in dialogue on a regular basis. 3. Opportunities for informed pluralistic public debate, seeking the expression of all relevant opinions, should be promoted. Article 19 – Ethics committees Independent, multidisciplinary and pluralist ethics committees should be established, promoted and supported at the appropriate level in order to: (a) assess the relevant ethical, legal, scientific and social issues related to research projects involving human beings; (b) provide advice on ethical problems in clinical settings; (c) assess scientific and technological developments, formulate recommendations and contribute to the preparation of guidelines on issues within the scope of this Declaration; (d) foster debate, education and public awareness of, and engagement in, bioethics. Article 21 – Transnational practices 1. States, public and private institutions, and professionals associated with transnational activities should endeavor to ensure that any activity within the scope of this Declaration, undertaken, funded or otherwise

159 pursued in whole or in part in different States, is consistent with the principles set out in this Declaration. 2. When research is undertaken or otherwise pursued in one or more States (the host State(s)) and funded by a source in another State, such research should be the object of an appropriate level of ethical review in the host State(s) and the State in which the funder is located. This review should be based on ethical and legal standards that are consistent with the principles set out in this Declaration. 3. When negotiating a research agreement, terms for collaboration and agreement on the benefits of research should be established with equal participation by those party to the negotiation. 4. States should take appropriate measures, both at the national and international levels, to combat bioterrorism and illicit traffic in organs, tissues, samples, genetic resources and genetic-related materials. Promotion of the Declaration Article 22 – Role of States 1. States should take all appropriate measures, whether of a legislative, administrative or other character, to give effect to the principles set out in this Declaration in accordance with international human rights law. Such measures should be supported by action in the spheres of education, training and public information. Article 23 – Bioethics education, training and information 1. In order to promote the principles set out in this Declaration and to achieve a better understanding of the ethical implications of scientific and technological developments, in particular for young people, States should endeavor to foster bioethics education and training at all levels as well as to encourage information and knowledge dissemination pro- grammers about bioethics. Article 25 – Follow-up action by UNESCO 1. UNESCO shall promote and disseminate the principles set out in this Declaration. In doing so, UNESCO should seek the help and assistance of the Intergovernmental Bioethics Committee (IGBC) and the Interna- tional Bioethics Committee (IBC). Final provisions Article 26 – Interrelation and complementarity of the principles This Declaration is to be understood as a whole and the principles are to be understood as complementary and interrelated. Each principle is to

160 be considered in the context of the other principles, as appropriate and relevant in the circumstances. Article 27 – Limitations on the application of the principles If the application of the principles of this Declaration is to be limited, it should be by law, including laws in the interests of public safety, for the investigation, detection and prosecution of criminal offences, for the protection of public health or for the protection of the rights and freedoms of others. Any such law needs to be consistent with international human rights law.

DECLARATION OF TOKYO Guidelines for Medical Doctors concerning Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment in relation to Detention and Imprisonment A problem of increasing occurrence - and repugnance - had been the methods of interrogation and torture perpetrated upon prisoners and detained persons. Some governments had attempted to enlist the assistance of physicians to monitor these activities. The WMA attempted to deal with such incidents as they arose. But as reports of such incidents began to multiply, it became evident that a professional guideline for physicians was needed. Early in 1974, the British Medical Association (BMA) notified the WMA about medical aspects of torture with special reference to happenings in Northern Ireland. A document prepared by the BMA's Cen- tral Ethical Committee stated that so far as the United Kingdom, the territories under its control, and BMA members were concerned. The Committee held the view that in such circumstances as those occurring in Northern Ireland, a doctor's duty, as always, lied in the prevention and treatment of illness, and in the care of the wounded. No doctors should take part, directly or indirectly in interrogation procedures. The BMA documents concluded with the suggestion that the wider issues of the matter should be discussed by the WMA. It noted that some of form of International Medical Commission should try to see that mental damage did not occur under intensive interrogation, to subjects who in many cases had not been tried in a normal Court of Law. The BMA foresaw grave ethical difficulties where local doctors were drawn into such situations.

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The same year, the WMA Council took particular note of the medical ethics involved in this problem. It was not confined only to the situation in North Ireland. Doctors in the U.K. armed forces were cry- ing out for advice as to what policy they should adopt. During discussion at the Assembly in Stockholm, in 1974, the British Medical Asso- ciation offered to assist in the study of the issue, and so did the Irish Medical Association which was interested also on account of the cases of torture existing in Ireland. The French Medical Federation provided also some documents related to the subject. One of the most difficult and important task facing the WMA Coun- cil and its Committee on Medical Ethics was the preparation of a guideline for medical doctors relative to torture and other cruel, inhuman or degrading treatment or punishment in relation to detention and imprisonment. With the tremendous amount of work done by the three associations named above, it had been possible to prepare a draft statement which was sent to the Tokyo Assembly where it was unanimously adopted. It is worthwhile to mention that the WHO had requested WMA's cooperation in the development of a statement on this topic which would be forwarded to the Fifth U.N. Congress on Crime and treatment of Offenders. The UN Congress used the WMA Declaration as a background paper. The Tokyo Declaration has not been revised since its adoption in 1975.

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TOKYO DECLARATION World Medical Association Declaration Guidelines for Medical Doctors Concerning Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention and Imprisonment Adopted by the 29th World Medical Assembly Tokyo, Japan, October 1975

Date Approved: October 1975

PREAMBLE It is the privilege of the medical doctor to practice medicine in the service of humanity, to preserve and restore bodily and mental health without distinction as to persons, to comfort and to ease the suffering of his or her patients. The utmost respect for human life is to be maintained even under threat, and no use made of any medical knowledge contrary to the laws of humanity. For the purpose of this Declaration, torture is defined as the deliberate, systematic or wanton infliction of physical or mental suffering by one or more persons acting alone or on the orders of any authority, to force another person to yield information, to make a confession, or for any other reason. 1. The doctor shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures, whatever the offence of which the victim of such procedures is suspected, accused or guilty, and whatever the victim's beliefs or motives, and in all situations, including armed conflict and civil strife. 2. The doctor shall not provide any premises, instruments, substanc- es or knowledge to facilitate the practice of torture or other forms of cruel, inhuman or degrading treatment or to diminish the ability of the victim to resist such treatment. 3. The doctor shall not be present during any procedure during which torture or other forms of cruel, inhuman or degrading treatment is used or threatened. 4. A doctor must have complete clinical independence in deciding upon the care of a person for whom he or she is medically responsible. The doctor's fundamental role is to alleviate the distress of his or her

163 fellow men, and no motive whether personal, collective or political shall prevail against this higher purpose. 5. Where a prisoner refuses nourishment and is considered by the doctor as capable of forming an unimpaired and rational judgment concerning the consequences of such a voluntary refusal of nourishment, he or she shall not be fed artificially. 'Me decision as to the capacity of the prisoner to form such a judgment should be confirmed by at least one other independent doctor. The consequences of the refusal of nourishment shall be explained by the doctor to the prisoner. 6. The World Medical Association will support, and should encourage the international community, the national medical associations and fellow doctors, to support the doctor and his or her family in the face of threats or reprisals resulting from a refusal to condone the use of torture or other forms of cruel, inhuman or degrading treatment.

DECLARATION OF HELSINKI (1964) Recommendations guiding physicians in biomedical research involving human subjects. Adopted by the 18th World Medical Assembly, Helsinki, Finland, June 1964, amended by the 29th World Medical Assembly, Tokyo, Ja- pan, October 1975, and the 35th World Medical Assembly, Venice, Italy, October 1983.

Introduction It is the mission of the physician to safeguard the health of the people. His or her knowledge and conscience are dedicated to the fulfill- ment of this mission. The purpose of biomedical research involving human subjects must be to improve diagnostic, therapeutic and prophylactic procedures and the understanding of the etiology and pathogenesis of disease. In current medical practice most diagnostic, therapeutic or prophylactic procedures involve hazards. This applies especially to biomedical research. Medical progress is based on research which ultimately must rest in part on experimentation involving human subjects. In the field of biomedical research a fundamental distinction must be recognized between medical research in which the aim is essentially diagnostic or therapeu-

164 tic for a patient, and medical research the essential object of which is purely scientific and without implying direct diagnostic or therapeutic value to the person subjected to the research. Special caution must be exercised in the conduct of research which may affect the environment, and the welfare of animals used for research must be respected. Because it is essential that the results of laboratory experiments be applied to human beings to further scientific knowledge and to help suffering humanity, the World Medical Association has prepared the following recommendations as a guide to every physician in biomedical research involving human subjects. They should be kept under review in the future. It must be stressed that the standards as drafted are only a guide to physicians all over the world. Physicians are not relieved from criminal, civil and ethical responsibilities under the law of their own countries. I. Basic Principles Biomedical research involving human subjects must conform to generally accepted scientific principles and should be based on adequately performed laboratory and animal experimentation and on a thorough knowledge of the scientific literature. The design and performance of each experimental procedure involving human subjects should be clearly formulated in an experimental protocol which should be transmitted to a specially appointed independent committee for consideration, comment and guidance. Biomedical research involving human subjects should be conducted only by scientifically qualified persons and under the supervision of a clinically competent medical person. The responsibility for the human subject must always rest with a medically qualified person and never rest on the subject of the research, even though the subject has given his or her consent. Biomedical research involving human subjects cannot legitimately be carried out unless the importance of the objective is in proportion to the inherent risk to the subject. Every biomedical research project involving human subjects should be preceded by careful assessment of predictable risks in comparison with foreseeable benefits to the subject or to others. Concern for the

165 interests of the subject must always prevail over the interests of science and society. The right of the research subject to safeguard his or her integrity must always be respected. Every precaution should be taken to respect the privacy of the subject and to minimize the impact of the study on the subject's physical and mental integrity and on the personality of the subject. Physicians should abstain from engaging in research projects involving human subjects unless they are satisfied that the hazards involved are believed to be predictable. Physicians should cease any investigation if the hazards are found to outweigh the potential benefits. In publication of the results of his or her research, the physician is obliged to preserve the accuracy of the results. Reports of experimentation not in accordance with the principles laid down in this Declaration should not be accepted for publication. In any research on human beings, each potential subject must be adequately informed of the aims, methods, anticipated benefits and potential hazards of the study and the discomfort it may entail. He or she should be informed that he or she is at liberty to abstain from participation in the study and that he or she is free to withdraw visor her consent to participation at any time. The physician should then obtain the subject's freely given informed consent, preferably inheriting. When obtaining informed consent for the research project the physician should be particularly cautious if the subject is in dependent relationship to him or her or may consent under duress. In that case the informed consent should be obtained by a physician who isn't engaged in the investigation and who is completely independent of this official relationship. In case of legal incompetence, informed consent should be obtained from the legal guardian in accordance with national legislation. Where physical or mental incapacity makes it impossible to obtain informed consent, or when the subject is a minor, permission from the responsible relative replaces that of the subject in accordance with national legislation. Whenever the minor child is in fact able to give a consent, the minor's consent must be obtained in addition to the consent of the mi- nor's legal guardian.

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The research protocol should always contain a statement of the ethical considerations involved and should indicate that the principles enunciated in the present declaration are complied with. II. Medical Research Combined with Professional Care (Clinical Research) In the treatment of the sick person, the physician must be free to use a new diagnostic and therapeutic measure, if in his or her judgment it offers hope of saving life, re-establishing health or alleviating suffering. The potential benefits, hazards and discomfort of a new method should be weighed against the advantages of the best current diagnostic and therapeutic methods. In any medical study, every patient- including those of a control group, if any- should be assured of the best proven diagnostic and therapeutic method. The refusal of the patient to participate in a study must never inter- fere with the physician-patient relationship. If the physician considers it essential not to obtain informed consent, the specific reasons for this proposal should be stated in the experimental protocol for transmission to the independent committee (1, 2). The physician can combine medical research with professional care, the objective being the acquisition of new medical knowledge, only to the extent that medical research is justified by its potential diagnostic or therapeutic value for the patient. III. Non-Therapeutic Biomedical Research Involving Human Sub- jects (Non-Clinical Biomedical Research) In the purely scientific application of medical research carried out on a human being, it is the duty of the physician to remain the protector of the life and health of that person on whom biomedical research is being carried out. The subjects should be volunteers- either healthy persons or patients for whom the experimental design is not related to the patient's illness. The investigator or the investigating team should discontinue the research if in his/her or their judgment it may, if continued, be harmful to the individual. In research on man, the interest of science and society should never take precedence over considerations related to the well-being of the subject.

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THE ETHICAL COMMITTEE OF YSMU

The Ethical Committee (EC) is a non-governmental organization and an expert unit adjacent to YSMU. The main purpose of this NGO is to: a. Implement an independent expert analysis of medical research activities and projects and implementation of their possible results. The structure and activities of EC 2.1 EC has a general secretary and staff which organized its activities. The executive body of EC is its highest professional council, which meets once a month. The professional council includes famous scientists, clinicians and practicing doctors of the republic. During the meetings of professional council of EC the emergent issues are considered, which later are discussed in extended meetings of EC. If necessary the professional council of EC can create temporary expert groups for considering a given research issue or project. The decisions of the extended EC meetings are made by simple majority of votes of leading specialists. The changes in the charter of EC are made by the extended sessions of EC by simple majority of votes.

The rights and duties of EC 3.1 EC must assess the professional competence of the researcher EC. must provide an evaluation of proposed research plan and decide its urgency, its potential to lead to valuable scientific results and evaluate the social risk it poses. 3.3 EC must provide a written consent form for a given specialist to participate in a given research. EC must evaluate the completeness and accuracy of information provided in the written application of the researcher. EC must evaluate the level of risk of the suggested research method. 3.6 Evaluate criteria of volunteer participation implemented in selection of a given human subject participating in a medical experi-

168 mentation. YSMU may disapprove any research proposal even if these research proposals were approved by other ethical committees. EC must present its annual report in annual conference. EC review all applications and decisions regarding these applications. If necessary, EC may organize a session on the discussed issue with participation of local or international experts. If necessary, EC may send the proposed research project abroad for expert review.

EC Tasks 4.1 To study ethical aspects of clinical and experimental research projects. 4.2 Assess the level of validity and necessity of suggested research projects. Assess the level of urgency of the discussed issue. Assess the innovative character of proposed research. Assess the practical significance and importance of proposed research. 4.3 Ensure the confidentiality of information regarding the research. 4.4 Ensure the estimation of risks for human subjects participating in research and the development of means for preventing such risks. 4.5 Ensure supervision of implementation of research projects through a corresponding monitoring process.

Main Principles of EC Activities 5.1 When making decisions EC relies on the Constitution of RA and current laws. When making decision EC relies on principles Universal Declara- tion of Human Rights adopted by UNO, on corresponding points of Helsinki Declaration as well as on requirements of World Health Organization.

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The RA Law on Medical Aid and Medical Service (Adopted on March 4, 1996)

The RA Law on ensuring population’s sanitary and epidemic security (Adopted by the Highest Council of RA on November 16, 1992). Human Rights in the Field of Medical Aid and Medical Service (With abbreviations) Article 4. The human right to receive medical aid and service Article 5. The human rights when receiving medical aid and service Article 6. The human right to get compensation for the harm received during medical aid or service. Article 7. The human right to receive information regarding the health condition. Article 8. Informed consent for medical intervention. Article 9. The human right for reproduction. Article 10. The child’s right to receive medical aid and service. Article 11. The rights of people who pose threat to surrounding people. Article 12. Prisoners’ right to receive medical aid and service. Article 13. The right to receive medical aid and service in the ar- my. Article 14. The right to receive medical aid and service of people who were harmed in an accident. Article 15. The right to receive medical aid and service of people who are foreign citizens and who have no citizenship. Article 16. Medical aid and service without consent. Article 17. Refusing medical intervention. Providers of medical aid and service and their rights Article 19. Rights and duties of providers of medical aid and service. Special types of medical aid and service and forms of organizing them Article 23. Prohibition of euthanasia. Article 27. Duties of medical institutions in providing information regarding side effects of medication.

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LEGAL REGULATIONS OF THE INSTITUTE OF FAMILY DOCTORS IN REPUBLIC OF ARMENIA

According to the time schedule adopted by decision # 1533 of No- vember 13, 2003 by the Government of Republic of Armenia, the Re- public of Armenia decides: 1. To approve, a. The statements of activities of family doctors according to the appendix b. The form of provision of information about the family doctor according to the appendix c. This decision has legal power from the next day after publication. Statements about the activities of family doctors 1. Main directions and principles of activities of family doctors. The family doctor is the physician who provides medical-social assistance to family members (without discrimination on basis of age, gender, ethnic belonging and religion) and who has a right and corresponding professional training for providing such assistance. The family doctor promotes healthy life style, prevents diseases, provides primary medical aid and restores health using his/her knowledge of patients family, professional and social conditions. Only those who have completed corresponding courses and who have received corresponding professional qualification may work as a family doctor. The family doctor provides primary medical aid individually, with a group (in partnership with other family doctors) and with a team (a team includes other professionals, such as pediatrician, gynecologist, a dentist etc.). A family doctor may be employed in any medical institution or establish his/her own enterprise according to the law of RA. A family doctor (or a group of family doctors) may create a contract with state or community organizations as well as with medical insurance and other companies. A family doctor does ambulatory admissions, makes visits to homes, provides emergency medical aid, preventive, diagnostic, medi-

171 cal and rehabilitating medical service, participates in solving medical- social and health protection issues of the family. The family doctor is led by these principles and legal acts regarding protection of peoples’ health. The supervision of family doctors’ activities is implemented by the Ministry of Health of Republic of Armenia as an entity which provides qualification license and provides state orders. A family doctor must be aware of fundamentals of RA law on provision of medical aid to public, he/she must be aware of the structure and main principles of activities of health system of RA, know his/her professional rights and duties. A family doctor must be able to plan his/her work, implement a health prevention analysis and cooperate with other professional and services. A family doctor must observe the rules of medical ethics. A family doctor is responsible for decisions made independently and is subject to RA law for illegal actions as well as neglected necessary actions which have caused harm to patient’s health or has caused death.

2. Professional Competency of Family Doctors The family doctor must master the following types of medical activities. a. Prevention, diagnosis, medical treatment and restoration of health for most widespread diseases. b. Urgent medical treatment and medical interventions c. Organizational skills Prevention, diagnosis, medical treatment and restoration of patient health The family doctor must: a. Be skilled in methods of protection of public health. b. Be able to examine a patient and estimate examination results c. Form a plan for an instrumental research d. Interpret the results of blood, urine, X-ray etc. test results e. Be skilled in prevention, diagnosis, medical treatment and restoration of health for most widespread diseases.

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f. Be able to organized additional examination, consultation and hospitalization when necessary. 17. The Family Doctor Must Have a. General professional skills b. Neurological skills c. Minimum skills for curing diseases related to nose, throat and ear. d. Professional skills for pediatrics. e. Professional skills for oncology.

Moral issues of preventive medicine Food additives The issue of food additives is an important bioethical issue. On the one hand, to serve the general public with high quality, safe, healthy and taste food, the use of extra additives are necessary, on the other hand, it has been registered numerous times, that the extra additives are being abused and in certain cases, the additives can be harmful to people’s health and even dangerous for their life. The most reliable way to address the issue of additives is to educate the general public, that is the consumers. Below is a very brief and general description of various additives as well as a short list of dangerous additives. E100-E182 added for coloring they stress or restore the color of products E200 – E299 added as conservatives they help to conserve the product for longer time by protecting it from microbes, mushrooms E300-E399 added as anti-acids chemical stabilizing additives. They protect the food from acidic processes E400-E499 added as stabilizers they preserve the initial thickness and texture of the product E500-E599 added as emulgator they help to create a homogeneous substance, for instance, from oil and water E600-E699 They strengthen the taste and the odor E900-E999 They prevent or decrease the sparkling level

The use of some additives is forbidden in many countries. For example,

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E121 – citrus coloring additive 2, E123 – red coloring and scant additive, E240 – conservative formaldehyde are forbidden in Russia. The following additives are classified as dangerous: • The additives E103, E105, E121, E123, E125, E126, E130, E131, E142, E152, E210, E211, E213-217, E240, E330 and E447 are believed to bring malicious tumor. • The additives E221-226, E320-322, E338-341, E407, E450, and E461-466 are believed to bring diseases of gastric and in- testine system. • The additives E230, E231, E232, E239, and E311-313 are highly potent for creating allergies. • The additives E171-173, E320-322 bring forth liver and kidney disorders. A more detailed description of twelve highly dangerous food additives are as follows6. Propyl Gallate This preservative, used to prevent fats and oils from spoiling, might cause cancer. It's used in vegetable oil, meat products, potato sticks, chicken soup base and chewing gum, and is often used with BHA and BHT (see below). BHA and BHT Butylated hydroxyanisole (BHA) and butylated hydroxytoluene (BHT) are used similarly to propyl gallate -- to keep fats and oils from going rancid. Used commonly in cereals, chewing gum, vegetable oil and potato chips (and also in some food packaging to preserve fresh- ness), these additives have been found by some studies to cause cancer in rats. If a brand you commonly buy uses these additives, look for a different variety, as not all manufacturers use these preservatives. Potassium Bromate This additive is used in breads and rolls to increase the volume and produce a fine crumb structure. Although most bromate breaks down into bromide, which is harmless, the bromate that does remain causes cancer in animals. Bromate has been banned throughout the world, ex-

6 The text regarding these harmful ingredients was adopted from http://www.sixwise.com/newsletters/06/04/05/12-dangerous-food-additives- the-dirty-dozen-food-additives-you-really-need-to-be-aware-of.htm 174 cept for in the United States and Japan. In California, a cancer warning would likely be required if it were used, which is why it is rarely used in that state. Monosodium glutamate (MSG) MSG is used as a flavor enhancer in many packaged foods, including soups, salad dressings, sausages, hot dogs, canned tuna, potato chips and many more. According to Dr. Russell Blaylock, an author and neurosurgeon, there is a link between sudden cardiac death, particularly in athletes, and excitotoxic damage caused by food additives like MSG and artificial sweeteners. Excitotoxins are, according to Dr. Blaylock, "A group of excitatory amino acids that can cause sensitive neurons to die." Many consumers have also personally experienced the ill effects of MSG, which leave them with a headache, nausea or vomiting after eat- ing MSG-containing foods. Aspartame (Equal, NutraSweet) This artificial sweetener is found in Equal and NutraSweet, along with products that contain them (diet sodas and other low-cal and diet foods). This sweetener has been found to cause brain tumors in rats as far back as the 1970s, however a more recent study in 2005 found that even small doses increase the incidence of lymphomas and leukemia in rats, along with brain tumors. People who are sensitive to aspartame may also suffer from head- aches, dizziness and hallucinations after consuming it. Acesulfame-K Acesulfame-K is an artificial sweetener that's about 200 times sweeter than sugar. It's used in baked goods, chewing gum, gelatin des- serts and soft drinks. Two rat studies have found that this substance may cause cancer, and other studies to reliably prove this additive's safety have not been conducted. Acesulfame-K also breaks down into acetoacetamide, which has been found to affect the thyroid in rats, rab- bits and dogs. Olestra Olestra is a fat substitute used in crackers and potato chips, marketed under the brand name Olean. This synthetic fat is not absorbed by the body (instead it goes right through it), so it can cause diarrhea, loose stools, abdominal cramps and flatulence, along with other effects. Fur-

175 ther, olestra reduces the body's ability to absorb beneficial fat-soluble nutrients, including lycopene, lutein and beta-carotene. Sodium Nitrite (Sodium Nitrate) Sodium nitrite (or sodium nitrate) is used as a preservative, coloring and flavoring in bacon, ham, hot dogs, luncheon meats, corned beef, smoked fish and other processed meats. These additives can lead to the formation of cancer-causing chemicals called nitrosamines. Some studies have found a link between consuming cured meats and nitrite and cancer in humans. Hydrogenated Vegetable Oil The process used to make hydrogenated vegetable oil (or partially hydrogenated vegetable oil) creates trans fats, which promote heart disease and diabetes. The Institute of Medicine has advised that consumers should eat as little trans fat as possible. You should avoid anything with these ingredients on the label, which includes some margarine, vegetable shortening, crackers, cookies, baked goods, salad dressings, bread and more. It's used because it reduces cost and increases the shelf life and flavor stability of foods. Blue 1 and Blue 2 Blue 1, used to color candy, beverages and baked goods, may cause cancer. Blue 2, found in pet food, candy and beverages, has caused brain tumors in mice. Red 3 This food coloring is used in cherries (in fruit cocktails), baked goods and candy. It causes thyroid tumors in rats, and may cause them in humans as well. Yellow 6 As the third most often used food coloring, yellow 6 is found in many products, including backed goods, candy, gelatin and sausages. It has been found to cause adrenal gland and kidney tumors, and contains small amounts of many carcinogens. According to Asghik Hrachyan from Paris, there is a grand list of food additives which should be avoided in all amounts. These additives include. Medical expenditures of World Countries Money is distributed very unevenly in the world. This fact has a huge influence on the picture of medical service on the globe. Below,

176 the annual health expenditures in different countries per capita are presented. The sum of public and private expenditure (in purchasing power parity terms in US dollars), divided by the population. Health expenditure includes the provision of health services (preventive and curative), family planning activities, nutrition activities, and emergency aid des- ignated for health, but excludes the provision of water and sanitation.

Highest expenditure per capita Expenditure Expenditure Country per capita Country per capita (in US $) (in US $) Iceland 3,294 Norway 4,080 Australia 3,123 Canada 3,173 Ireland 2,618 Sweden 2,828 Switzerland 4,011 Japan 2,293 Netherlands 3,092 France 3,040 Finland 2,203 United States 6,096 Spain 2,099 Denmark 2,780 Austria 3,418 United Kingdom 2,560 Belgium 3,133 Luxembourg 5,178 New Zealand 2,081 Italy 2,414 Hong Kong n.a. Germany 3,171 Israel 1,972 Greece 2,179 Korea (Republic Singapore 1,118 1,135 of) Slovenia 1,815 Cyprus 1,128 Portugal 1,897 Brunei Darussalam 1,897

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Lowest expenditure per capita Expenditure Expenditure Country per capita Country per capita (in US $) (in US $) Sierra Leone 34 Angola 38 Zimbabwe 139 Niger 26 Sudan 54 Mozambique 42 Central African 54 Chad 42 Republic Congo, Dem. Ethiopia 21 15 Rep. of the Burundi 16 Côte d'Ivoire 64 Zambia 63 Malawi 58 Rwanda 126 Guinea 96 Tanzania 29 Nigeria 53 Eritrea 27 Senegal 72 Gambia 88 Haiti 82 Yemen 82 Kenya 86

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E 102 E104 E 110 E 120 E 122 E 123 E 124 E 127 E 128 E 129 E 131 E 142 E 151 E 154 E 155 E 161g E 173 E 174 E 175 E 180 E 210 E 211 E 212 E 213 E 214 E 215 E 216 E 217 E 218 E 219 E 220 E 221 E 222 E 223 E 224 E 226 E 227 E 228 E 239 E 242 E 249 E 250 E 251 E 252 E 284 E 285 E 310 E 311 E 312 E 315 E 316 E 320 E 321 E 380 E 385 E 407 E 407a E 431 E 432 E 433 E 434 E 435 E 436 E 442 E 459 E 491 E 492 E 493 E 494 E 495 E 496 E 512 E 520 E 521 E 522 E 523 E 541 E 554 E 555 E 556 E 620 E 621 E 622 E 623 E 624 E 625 E 900 E 905 E 951 E 952 E 954 E 955 E 962 E 999 E 1201 E 1202

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GLOSSARY OF BIOETHICAL TERMS

Abortion: Intentionally causing the death of a fetus in utero, by either active or passive means. (See below) Active Euthanasia: Mercy-killing; direct act of physically killing a sick or dying person. Animal Rights Advocacy: That moral position which holds that animals other than human can have rights. Animal Welfare Advocacy: That moral position which holds that all animals deserve humane treatment. Assisted Suicide: Helping to provide someone with the means to self-kill. Any moral agent can be complicit in this act. Autonomy: Self-rule, capacity for mature, uncoerced and therefore mentally competent decision-making; not the same as a liberty or right to choose this or that specific action, since this mental capacity is the prior condition of possibility of any competent decision.. Beneficence: doing well by someone; well-meaning intent and behavior. Circularity: The logical error of question-begging; to assume as true or given that which is also to be argued for; to have the conclusion simply re-state the premiss. Competence: Capability of a mature person to reason and to choose autonomously. Complicit Moral Agency: agreement in action or intent between two or more moral agents. Conflict of Interest: A mind-state of having competing goals or intentions. Euthanasia: A moral agent’s intentional causing of a patient’s earlier than natural death, either actively or passively. Genetic Mother: The woman who contributes her ovum for gestation. Gestational Mother: The woman who is pregnant. 180

Harm Principle: Moral maxim which holds that one is not free to cause harm to others, attributed to J.S. Mill.. Involuntary: That which is imposed upon a person despite that person’s objection. Justice: Fairness or treating all equally. Justification: Supporting reason for an action or decision which renders it morally acceptable. Moral Agency: Capability of discerning right and wrong. Natural Law: a source of law that arises out of human nature itself, innate, inborn, and which determines species characteristics, like moral agency or capacity to understand and think. Non-Voluntary: That which is chosen on behalf of an incompetant person. Nurturing Mother: The woman who raises a child who may or may not be her own biological offspring. Palliative Care: Comfort care for those in pain, pain management, hospice care, etc. Passive Euthanasia: Letting die, or allowing to die of a sick or dying person by any moral agent (including the patient himself) who is specifically intending to help bring about an earlier than natural death for that person. Passive Infanticide: Intentionally letting an infant die from ne- glect of its needs. Paternalism: Suppressing an individual’s autonomy for that person’s own sake. Personhood: That moral status which is worthy of highest respect, and possessive of rights. Physical Sentience: The capacity to feel physical touch, or experience discomfort/pain. Rationality: Capability to reason or organize thoughts. Self-consciousness: Awareness of one’s identity, knowledge that one’s self endures over time.

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Supererogatory: Heroic or lofty behavior which goes beyond duty or obligation. Surrogate Motherhood: Pregnancy undertaken for the purpose of gestating a child for another. Total Extra-Corporeal Gestation: the growing of a human being entirely outside of the female body . Utilitarianism: That moral theory which holds that actions are good or bad depending on their consequences. Viability: The physical state of being able to remain alive unat- tached to another human being. Virtue: A habit of doing good. Voluntary: That which is chosen freely.

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Used internet resources 1. http://biblescripture.net/Abortion.html 2. http://ethics.iit.edu/codes/coe/world.med.assoc.tokyo.html 3. http://portal.unesco.org/en/ev.php- URL_ID=31058&URL_DO=DO_TOPIC&URL_SECTION=2 01.html 4. http://wings.buffalo.edu/faculty/research/bioethics/lwill.html 5. http://www.changesurfer.com/Hlth/DPReview.html 6. http://www.cirp.org/library/ethics/geneva/ 7. http://www.cirp.org/library/ethics/helsinki/ 8. http://www.cirp.org/library/ethics/hippocrates/ 9. http://www.cirp.org/library/ethics/intlcode/ 10. http://www.infoplease.com/ipa/A0934556.html 11. http://www.jesuschristsavior.net/Ethics.html 12. http://www.nrlc.org/euthanasia/facts/keypoints.html 13. http://www.nvcc.edu/home/mgregory/bioethics_glossary.htm 14. http://www.sixwise.com/newsletters/06/04/05/12-dangerous- food-additives-the-dirty-dozen-food-additives-you-really-need- to-be-aware-of.htm 15. http://www.restoringourheritage.com/articles/nej_medicaldictat orship.pdf 16. http://www.wma.net/e/history/tokio.htm 17. www.ama-assn.org/ama/pub/category/2910.html 18. www.ama-assn.org/ama/pub/category/5689.html 19. www.hospicecare.com/Ethics/ethics.htm 20. www.hsph.harvard.edu/bioethics/ 21. www.nih.gov/sigs/bioethics/endoflife.html 22. www.nofreelunch.org 23. www.unadids.org/en/in+focus/hiv_aids_human_rights/unaids+ activities+hr.asp 24. www.who.int/ethics/research/en/ 25. www.who.int/ethics/topics/cloning/en/ 26. www.who.int/reproductive-health/infertility/report_content.htm 27. www.wits.ac.za/bioethics 28. www.wma.net 29. www.wuthanasia.com

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Printed sources 1. Medical Ethics Manual, World Medical Association, France, 2005 2. Informed Consent, Edited by Amnon Carmi, Israel, 2003. 3. Universalism and Ethical Values for Enviroment, UNESCO, 2010. Printed in Tailand. Edited by Darry R.J. Macer. 4. Law and Medical Ethics, Mason J. K. Laurie, G. T. Oxford, 2006 5. Resolving Ethical Dilemmas: A Guide for Clinicians, Bernard Lo, Williams & Wilkins, 1995 6. Ethical Review of Biomedical Research in the CIS Countries (Social and Cultural Aspects) Saint-Pitersburg, 2007 7. ¸³íÃÛ³Ý ê.Ð., ´Çá¿ÃÇÏ³ÛÇ ¹³ë³·Çñù, ºñ¨³Ý, 2009

Performances to attend (or books to read) 1. Aghasi Ayvazyan “The Physiology of the Nation” 2. Hakob Paronyan “The Eastern Dentist” 3. Hrant Matevosyan “The threes”. 4. Federico Garcia Lorka “Alba and her Daughters” 5. Tennessee Williams “Tramway of Wish” 6. Luckas Berfus “The Neurosis of our Parents”

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LITERATURE

1. ²ëïí³Í³ßáõÝã: 2. ´³µ³Û³Ý ². öáËÝ³Ï Ù³Ûñ»ñ: ¾É-²Ý¹ñ³¹³ñÓ, 67, Ù³ÛÇë, 2010: 3. ´ÅßÏ³Ï³Ý ë»ÕÙ³·ñ»ñÇ Ñ³ÛÏ³Ï³Ý Ñ³Ý¹»ë, ºñ¨³Ý, 2002- 2011, ¶ÉË. ËÙµ³·Çñ, µ.·.¹. åñáý. è.². ÐáíÑ³ÝÝÇëÛ³Ý: 4. ´Çá¿ÃÇÏ³ÛÇ ÝáñÙ»ñÝ áõ ëÏ½µáõÝùÝ»ñÁ, ï»Õ»Ï³óí³Í Ñ³Ù³Ó³ÛÝáõÃÛáõÝ, ´Çá¿ÃÇÏ³ÛÇÝ í»ñ³µ»ñáÕ ûñ»Ýë¹ñ³Ï³Ý ³Ïï»ñÁ ¨ ÝáñÙ»ñÁ, ºñ¨³Ý, 2004 (ÐÐ´¼À): 5. ¸³ñµÇÝÛ³Ý ì.¸. öÇÉÇëá÷³ÛáõÃÛ³Ý Ý»ñ³ÍáõÃÛáõÝ, ºñ¨³Ý, 2010. 6. ¸³íÃÛ³Ý ê.Ð. ´Çá¿ÃÇÏ³, ¹³ë³·Çñù, ºñ¨³Ý, 2009: 7. ¸³íÃÛ³Ý ê.Ð. ¾íÃ³Ý³½Ç³, §´ÅßÏáõÃÛáõÝ, ·ÇïáõÃÛáõÝ ¨ ÏñÃáõÃÛáõÝ¦, ÃÇí 3, 2009: 8. ¸³íÃÛ³Ý ê.Ð. ÐáíÑ³ÝÝ»ë â»ùÇçÛ³Ý, ºñ¨³Ý, 2000: 9. ¸³íÃÛ³Ý ê.Ð., ¶Çï³ï»ËÝÇÏ³Ï³Ý ³é³çÁÝÃ³óÇ Ñ»ï¨³ÝùÝ»ñÇ µÇá¿ÃÇÏ³Ï³Ý áõëáõÙÝ³ëÇñáõÃÛ³Ý ÑÇÙÝ³Ñ³ñó»ñ, ºä´Ð ¶Çï³ÅáÕáíÇ ÝÛáõÃ»ñ, ºñ¨³Ý, 2012: 10. ¸³íÃÛ³Ý ê.Ð. ´Çá¿ÃÇÏ³Ýª áñå»ë ÷ÇÉÇëá÷³ÛáõÃÛ³Ý ·áñÍÝ³Ï³Ý ¹ñë¨áñÙ³Ý ³ëå³ñ»½, §úñ»Ýù ¨ Çñ³Ï³ÝáõÃÛáõÝ¦, ÃÇí 6, ÑáõÝÇë, 2012 ºñ¨³Ý: 11. Î³ñ³å»ïÛ³Ý Ð. ÎÛ³ÝùÁ ß³ñáõÝ³ÏíáõÙ ¿, ºñ¨³Ý, 2005: 12. ÎáÙÇï³ë Ðá¹í³ÍÝ»ñ ¨ áõëáõÙÝ³ëÇñáõÃÛáõÝÝ»ñ, ºñ¨³Ý, 1941Ã.: 13. Ð³Ëí»ñ¹Û³Ý È. ¼ñáõÛóÝ»ñ É»½íÇ Ù³ëÇÝ, ºñ¨³Ý, 1986Ã. 14. Â³ÑÙÇ½Û³Ý Ü. ÎáÙÇï³ëÁ ¨ Ñ³Û ÅáÕáíñ¹Ç Å³é³Ý·áõÃÛáõÝÁ, ö³ë³¹»Ý³, 1994Ã.: 15. Ð³ÙÁÝ¹Ñ³Ýáõñ Ñéã³Ï³·Çñ µÇá¿ÃÇÏ³ÛÇ ¨ Ù³ñ¹áõ Çñ³íáõÝùÝ»ñÇ Ù³ëÇÝ, ºñ¨³Ý, 2006: 16. Ðñ» ¶áõÝ¹, ²Ùë³·Çñ, ºñ¨³Ý, 2007, #14 (158): 17. ØÇñ½áÛ³Ý ì. Î³é³í³ñÙ³Ý ÷ÇÉÇëá÷³ÛáõÃÛáõÝ, ºñ¨³Ý, 2010: 18. Ü³ñ»Ï³óÇ ¶. §Ø³ïÛ³Ý áÕµ»ñ·áõÃÛ³Ý¦, ºñ¨³Ý, 1970 19. ä³ÉÇ³ïÇí µÅßÏáõÃÛáõÝ, ºñ¨³Ý, 2007 20. ä³ÉÇ³ïÇí µÅßÏáõÃÛáõÝ : ´ÅßÏ³Ñá·»µ³Ý³Ï³Ý Ù»Ãá¹³Ï³Ý áõÕ»óáõÛó, ºñ¨³Ý, 2011

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