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Moral-ethic education of doctor.

Role of art in treatment of illness

Medical ethics is primarily a field of applied ethics, the study of moral values and
judgments as they apply tomedicine. As a scholarly discipline, medical ethics
encompasses its practical application in clinical settings as well as work on its history,
philosophy, theology, and sociology.

Medical ethics tends to be understood narrowly as an applied professional ethics,


whereas bioethics appears to have worked more expansive concerns, touching upon
the philosophy of science and the critique of biotechnology. Still, the two fields often
overlap and the distinction is more a matter of style than professional consensus.
Medical ethics shares many principles with other branches of healthcare ethics, such
as nursing ethics.

Values in medical ethics


Six of the values that commonly apply to medical ethics discussions are:

 Autonomy - the patient has the right to refuse or choose their treatment.
(Voluntas aegroti suprema lex.)
 Beneficence - a practitioner should act in the best interest of the patient. (Salus
aegroti suprema lex.)
 Non-maleficence - "first, do no harm" (primum non nocere).
 Justice - concerns the distribution of scarce health resources, and the decision of
who gets what treatment (fairness and equality).
 Dignity - the patient (and the person treating the patient) have the right to
dignity.
 Truthfulness and honesty - the concept of informed consent has increased in
importance since the historical events of the Doctors' Trial of the Nuremberg trials
and Tuskegee Syphilis Study.

Values such as these do not give answers as to how to handle a particular situation,
but provide a useful framework for understanding conflicts.

When moral values are in conflict, the result may be an ethical dilemma or crisis.
Writers about medical ethics have suggested many methods to help resolve conflicts
involving medical ethics. Sometimes, no good solution to a dilemma in medical ethics
exists, and occasionally, the values of the medical community (i.e., the hospital and
its staff) conflict with the values of the individual patient, family, or larger non-
medical community. Conflicts can also arise between health care providers, or among
family members. For example, the principles of autonomy and beneficence clash
when patients refuse life-saving blood transfusion, and truth-telling was not
emphasized to a large extent before the HIV era.

In the United Kingdom, General Medical Council provides clear overall modern
guidance in the form of its 'Good Medical Practice' statement. Other organisations,
such as the Medical Protection Society and a number of university departments, are
often consulted by British doctors regarding issues relating to ethics.

How does one ensure that appropriate ethical values are being applied within
hospitals? Effective hospital accreditation requires that ethical considerations are
taken into account, for example with respect to physician integrity, conflicts of
interest, research ethics and organ transplantation ethics.

Autonomy
The principle of autonomy recognizes the rights of individuals to self determination.
This is rooted in society’s respect for individuals’ ability to make informed decisions
about personal matters. Autonomy has become more important as social values have
shifted to define medical quality in terms of outcomes that are important to the
patient rather than medical professionals. The increasing importance of autonomy
can be seen as a social reaction to a “paternalistic” tradition within healthcare.[citation
needed]
Some have questioned whether the backlash against historically excessive
paternalism in favor of patient autonomy has inhibited the proper use of soft
paternalism to the detriment of outcomes for some patients[5]. Respect for autonomy
is the basis for informed consent and advance directives. Autonomy can often come
into conflict with Beneficence when patients disagree with recommendations that
health care professionals believe are in the patient’s best interest.[citation
needed]
Individuals’ capacity for informed decision making may come into question
during resolution of conflicts between Autonomy and Beneficence. The role of
surrogate medical decision makers is an extension of the principle of autonomy.

Autonomy is a general indicator of health. Many diseases are characterised by loss of


autonomy, in various manners. This makes autonomy an indicator for both personal
well-being, and for the well-being of the profession. This has implications for the
consideration of medical ethics: "is the aim of health care to do good, and benefit
from it?"; or "is the aim of health care to do good to others, and have them, and
society, benefit from this?". (Ethics - by definition - tries to find a beneficial balance
between the activities of the individual and its effects on a collective.)

By considering Autonomy as a gauge parameter for (self) health care, the medical
and ethical perspective both benefit from the implied reference to Health.

Beneficence
The term beneficence refers to actions that promote the wellbeing of others. In the
medical context, this means taking actions that serve the best interests of patients.
However, uncertainty surrounds the precise definition of which practices do in fact
help patients. Controversy arises when physicians disagree with the patient as to
what constitutes the patient's best interests--a situation in which the principles
of autonomyand beneficence conflict. When the patient's interests conflict with the
patient's welfare, different societies settle the conflict in a wide range of manners.
Western medicine generally defers to the wishes of a mentally competent patient to
make his own decisions, even in cases where the medical team believes that he is
not acting in his own best interests. However, many other societies prioritize
beneficence over autonomy.

James Childress and Tom Beauchamp in Principle of Bioethics (1978) identify


beneficence as one of the core values of health care ethics. Some scholars, such
as Edmund Pellegrino, argue that beneficence is the only fundamental principle of
medical ethics. They argue that healing should be the sole purpose of medicine, and
that endeavors like cosmetic surgery, contraception and euthanasia fall beyond its
purview.
Double effect

Some interventions undertaken by physicians can create a positive outcome while


also potentially doing harm. The combination of these two circumstances is known as
the "double effect." The most applicable example of this phenomenon is the use of
morphine in the dying patient. Such use of morphine can ease the pain and suffering
of the patient, while simultaneously hastening the demise of the patient through
suppression of the respiratory drive.

Informed consent
Informed consent in ethics usually refers to the idea that a person must be fully-
informed about and understand the potential benefits and risks of their choice of
treatment. An uninformed person is at risk of mistakenly making a choice not
reflective of his or her values or wishes. It does not specifically mean the process of
obtaining consent, nor the specific legal requirements, which vary from place to
place, for capacity to consent. Patients can elect to make their own medical
decisions, or can delegate decision-making authority to another party. If the patient is
incapacitated, laws around the world designate different processes for obtaining
informed consent, typically by having a person appointed by the patient or their next-
of-kin make decisions for them. The value of informed consent is closely related to
the values of autonomy and truth telling.

A correlate to "informed consent" is the concept of informed refusal.

Confidentiality
Confidentiality is commonly applied to conversations between doctors and
patients. This concept is commonly known as patient-physician privilege.

Legal protections prevent physicians from revealing their discussions with patients,
even under oath in court.

Confidentiality is mandated in America by HIPAA laws, specifically the Privacy Rule,


and various state laws, some more rigorous than HIPAA. However, numerous
exceptions to the rules have been carved out over the years. For example, many
states require physicians to report gunshot wounds to the police and impaired drivers
to the Department of Motor Vehicles. Confidentiality is also challenged in cases
involving the diagnosis of a sexually transmitted disease in a patient who refuses to
reveal the diagnosis to a spouse, and in the termination of a pregnancy in an
underage patient, without the knowledge of the patient's parents. Many states in the
U.S. have laws governing parental notification in underage abortion.[3]

Traditionally, medical ethics has viewed the duty of confidentiality as a relatively non-
negotiable tenet of medical practice. More recently, critics like Jacob Appel have
argued for a more nuanced approach to the duty that acknowledges the need for
flexibility in many cases. [6]

Criticisms of orthodox medical ethics


It has been argued that mainstream medical ethics is biased by the assumption of a
framework in which individuals are not simply free to contract with one another to
provide whatever medical treatment is demanded, subject to the ability to pay.
Because a high proportion of medical care is typically provided via the welfare state,
and because there are legal restrictions on what treatment may be provided and by
whom, an automatic divergence may exist between the wishes of patients and the
preferences of medical practitioners and other parties. Tassano[7] has questioned the
idea that Beneficence might in some cases have priority over Autonomy. He argues
that violations of Autonomy more often reflect the interests of the state or of the
supplier group than those of the patient.

Routine regulatory professional bodies or the courts of law are valid social recourses.

Importance of communication
Many so-called "ethical conflicts" in medical ethics are traceable back to a lack
of communication. Communication breakdowns between patients and their
healthcare team, between family members, or between members of the medical
community, can all lead to disagreements and strong feelings. These breakdowns
should be remedied, and many apparently insurmountable "ethics" problems can be
solved with open lines of communication.[citation needed]

Ethics committees
Many times, simple communication is not enough to resolve a conflict, and a hospital
ethics committee must convene to decide a complex matter. These bodies are
composed primarily of health care professionals, but may also include philosophers,
lay people, and clergy.

The assignment of philosophers or clergy will reflect the importance attached by


the society to the basic values involved. An example fromSweden with Torbjörn
Tännsjö on a couple of such committees indicates secular trends gaining influence.

Cultural concerns
Culture differences can create difficult medical ethics problems. Some cultures have
spiritual or magical theories about the origins of disease, for example, and reconciling
these beliefs with the tenets of Western medicine can be difficult.

Truth-telling
Some cultures do not place a great emphasis on informing the patient of the
diagnosis, especially when cancer is the diagnosis. Even American culture did not
emphasize truth-telling in a cancer case, up until the 1970s. In American medicine,
the principle of informed consenttakes precedence over other ethical values, and
patients are usually at least asked whether they want to know the diagnosis.
Online Business Practices
The delivery of diagnosis online leads patients to believe that doctors in some parts
of the country are at the direct service of drug companies. Finding diagnosis as
convenient as what drug still has patent rights on it. Physicians and drug companies
are found to be competing for top ten search engine ranks to lower costs of selling
these drugs with little to no patient involvement[8]

Conflicts of interest
Physicians should not allow a conflict of interest to influence medical judgment. In
some cases, conflicts are hard to avoid, and doctors have a responsibility to avoid
entering such situations. Unfortunately, research has shown that conflicts of interests
are very common among both academic physicians[9] and physicians in practice[10].
The The Pew Charitable Trusts has announced the Prescription Project for "academic
medical centers, professional medical societies and public and private payers to end
conflicts of interest resulting from the $12 billion spent annually on pharmaceutical
marketing".

Referral
For example, doctors who receive income from referring patients for medical tests
have been shown to refer more patients for medical tests [11]
. This practice is
proscribed by the American College of Physicians Ethics Manual [12]
.

Fee splitting and the payments of commissions to attract referrals of patients is


considered unethical and unacceptable in most parts of the world - while it is rapidly
becoming routine in other countries, like India, where many urban practitioners
currently pay a percentage of office-visit charges, lab tests as well as hospital care to
unaccredited "quacks", or semi-accredited "practitioners of alternative medicine",
who refer the patient. It is tolerated in some areas of US medical care as well.

Vendor relationships
Studies show that doctors can be influenced by drug company inducements,
including gifts and food. [13]
Industry-sponsored Continuing Medical Education (CME)
programs influence prescribing patterns. [14]
Many patients surveyed in one study
agreed that physician gifts from drug companies influence prescribing practices. [15]
A
growing movement among physicians is attempting to diminish the influence of
pharmaceutical industry marketing upon medical practice, as evidenced by Stanford
University's ban on drug company-sponsored lunches and gifts. Other academic
institutions that have banned pharmaceutical industry-sponsored gifts and food
include the University of Pennsylvania, and Yale University. [16]

Treatment of family members


Many doctors treat their family members. Doctors who do so must be vigilant not to
create conflicts of interest or treat inappropriately.[17][18].

Sexual relationships
Sexual relationships between doctors and patients can create ethical conflicts, since
sexual consent may conflict with the fiduciaryresponsibility of the physician. Doctors
who enter into sexual relationships with patients face the threats of deregistration
and prosecution. In the early 1990s it was estimated that 2-9% of doctors had
violated this rule[19]. Sexual relationships between physicians and patients' relatives
may also be prohibited in some jurisdictions, although this prohibition is highly
controversial.[20].

Art in treatment of illness


The Art of Being Well
Dr. Dráuzio Varella

..Speak your feelings.


Emotions and feelings that are hidden, repressed, end in illnesses as:
gastritis, ulcer, lumbar pains, spinal. With time, the repression of
the feelings degenerates to the cancer. Then, we go to a confidante, to
share our intimacy, ours "secret", our errors! The dialogue, the
speech, the word, is a powerful remedy and an excellent therapy!

If you don’t want to be ill...

If you don’t want to be ill...

...Make Decisions.

The undecided person remains in doubt, in anxiety, in anguish.


Indecision accumulates problems, worries and aggressions. Human history
is made of decisions. To decide is precisely to know to renounce, to
know to lose advantages and values to win others. The undecided people
are victims of gastric ailments, nervous pains and problems of the skin.

If you don’t want to be ill...

...Find Solutions.

Negative people do not find solutions and they enlarge problems. They
prefer lamentation, gossip, pessimism. It is better to light a match
that to regret the darkness. A bee is small, but produces one of the
sweetest things that exist. We are what we think. The negative thought
generates negative energy that is transformed into illness.
If you don’t want to be ill...

...Don’t Live By Appearances.

Who hides reality, pretends , poses and always wants to give the
impression of being well. He wants to be seen as perfect, easy-going,
etc. but is accumulating tons of weight. A bronze statue with feet of
clay. There is nothing worse for the health than to live on appearances
and facades. These are people with a lot of varnish and little root.
Their destiny is the pharmacy, the hospital and pain.

If you don’t want to be ill...

...Accept.

The refusal of acceptance and the absence of self-esteem, make us


alienate ourselves. Being at one with ourselves is the core of a
healthy life. They who do not accept this, become envious, jealous,
imitators, ultra-competitive, destructive. Be accepted, accept that you
are accepted, accept the criticisms. It is wisdom, good sense and
therapy.

If you don’t want to be ill...

...Trust.

Who does not trust, does not communicate, is not opened, is not
related, does not create deep and stable relations, does not know to do
true friendships. Without confidence, there is not relationship.
Distrust is a lack of faith in you and in faith itself.

If you don’t want to be ill...

...Do Not Live Life Sad.


Good humor. Laughter. Rest. Happiness. These replenish health and bring
long life. The happy person has the gift to improve the environment
wherever they live. “Good humor saves us from the hands of the doctor".
Happiness is health and therapy.

Art Therapy Helps Children Affected by Cancer Express Their Emotions

Simple lines, bright colors, and primitive shapes give the artwork a decidedly childlike quality, but the
scenes the young artists portray are disturbing—a floating house, a person jumping from a burning airplane,
a sinister bee that drinks blood.

The art that these young patients and children of patients create is “a window into the less-conscious mind,”
said Estela A. Beale, M.D., a child and adult psychiatrist and associate professor in the Department of
Neuro-Oncology at The University of Texas M. D. Anderson Cancer Center.

The premise behind art therapy—using a young patient’s art for a psychotherapeutic purpose—is that
creating pictures allows children to express what is uppermost in their minds more genuinely and
spontaneously than they are apt to do in a discussion with the therapist. “What is really important is to let
the children express themselves without any influence from an adult,” Dr. Beale said.

Pictures help the therapist understand the children’s perceptions and feelings about what is happening to
them and explore possible alternatives to solving problems, Dr. Beale said.

Sometimes the child’s art expresses this information quite graphically, but often the young artist’s thoughts
and feelings are “concealed, disguised, or expressed metaphorically,” Dr. Beale said.

The children’s art often expresses concepts they aren’t able to articulate. When asked what he thinks about
his illness, a young child may not be able to answer, but he can depict how he perceives his situation in a
painting or drawing. One eight-year-old patient, for instance, drew a picture of someone parachuting from
an airplane over water that is full of triangles.

“Oh, why is he jumping?” Dr. Beale asked.

“He’s jumping because the plane is on fire and about to explode,” the child told her. Beneath the man is an
island surrounded by sharks—the triangles. There is also a boat in the water, but it is empty, and the child
feared it might be dangerous to go there.

“Because of his illness, this child sees his life as threatened, and there is nowhere to turn for solace,
encouragement, or hope,” said Dr. Beale.

This is where the therapy begins. “In the therapeutic process, you have expression of feelings and an
opportunity to review the understanding of the illness, which is a cognitive process,” she said. Another very
important part of therapy is to help young patients find alternatives to deal with what they feel is ominous
or dangerous—to offer them hope.

Some children are able to talk about the feelings that inspired their artwork, but others become even more
frightened once they put their fears into the pictures, Dr. Beale said. To counteract this, she often keeps the
discussion in the picture’s metaphor. The children then, in their own time, work on the new ideas and
concepts she presents to them, until they feel more comfortable with their condition and with the questions
and fears that they experience, she said.

To the child who drew the burning plane and circling sharks, for example, Dr. Beale would not say, “Oh,
the plane is not going to burn down, and you don’t have to worry. We’re going to erase the fire,” because
that would not address the child’s terror. The plane, which is burning or disintegrating, clearly has
something to do with the child’s body, Dr. Beale said, and he wants to get away from it.

Instead, she would help the child to construct alternative solutions, such as finding safety for the man with
the parachute.

“Sometimes in life we feel that we are surrounded with danger,” she might tell the child. “I imagine you
feel that way when you are hurting and have to come back for chemotherapy and don’t know if you are
going to be able to get out of this.”

At this point, some children are willing to open up about their concerns, but other children affected by
cancer are too discouraged or frightened to respond. In such instances, Dr. Beale tries to offer hope in some
other area of their lives. For a child without medical problems, the therapy would probably emphasize
exploring his or her internal world, she said, but in a child with cancer, the therapy must help the child deal
with the illness and the fears it creates by offering an alternative to isolation as well as specific solutions
that can preserve the best possible quality of life.

“You are very frightened. What would help you?” Dr. Beale might ask the child. They could then discuss,
among other solutions, how the child’s parents could help.

The way children respond to a discussion of their illness is determined by how their parents talk to them
about cancer. Parents who are very open about sharing information have children who are very open about
their illness, their perceptions, and their fears, Dr. Beale said. “But if the parent
is too overwhelmed to permit discussion, the likelihood is that the child will be very timid about discussing
their disease and will avoid bringing things up, except to express them metaphorically.”

Another eight-year-old patient drew a picture for Dr. Beale of a house that seemed to be floating off the
ground. Even though her parents had told her little, the child knew she was very ill, but she had no clear
information about what was happening to her body. “She was up in the air,” Dr. Beale said.

Usually, the houses in children’s drawings represent the body, which contains life, Dr. Beale said. This
girl’s picture showed a primitive-looking house that was empty.

“This house is not on the ground, is it?” Dr. Beale asked her.

“No, this house is floating. It’s very light, and the people in the house like to float,” the child responded.

“But you know, this is a house that looks sad,” Dr. Beale observed.

“Yes, because all the neighbors are in another city.”

“That must be so lonesome, and I’m sure you know about that.”

The girl saw the connection and later started talking about how lonely she was, even when her mother was
present. She also came to understand what was happening to her, which helped to allay her anxiety and
reassure her.

Parents who do not discuss cancer with their children assume the child does not know what is happening.
Usually, they are wrong, Dr. Beale said. One three-and-a-half-year-old child who was not told about her
mother’s cancer drew a picture of her with hair— even though the woman was bald from chemotherapy—
and insisted that she preferred “mother with hair and no cancer!” According to Dr. Beale, the child knew
her mother was sick and was expressing a desire for her to be well.

Parents often think that they are protecting their children by refusing to discuss the child’s illness and
telling them, “Don’t worry. Everything is going to be okay.” But in reality, when children aren’t allowed to
express their concerns, they can feel isolated and more fearful, Dr. Beale said. The child’s resulting despair
is as much about the lack of human connection as it is about the illness.

In contrast, a seven-year-old child with leukemia whose mother had discussed her illness with her drew a
picture of a monster bee that killed people and “likes to eat blood.”

“He wants to be invisible,” the child told Dr. Beale, “but he can’t.” The cancer, Dr. Beale explained, was a
clear enemy.

“If parents can just listen and not be judgmental or prematurely reassuring, they can metabolize the feelings
and return them to the child in a more acceptable way,” she said.

This is part of what Dr. Beale does in therapy with the children. “Catharsis alone is not enough,” she said.
The children have to be able to express their fears in the context of an accepting relationship. This helps to
contain some of the anxieties they are experiencing, which can lead to reframing or expressing things in a
different way. “When children find some answers to their fears in the context of a trusting relationship,
hope improves—even if their illness does not,” Dr. Beale said.