- KANG Shinik Korea
In contemporary literature, the newly coined word 'bioethics' is more widely used than the traditional term 'medical ethics'. 'Bio-medical ethics' or 'professional ethics' is even less popular. But, I propose, the emphasis on 'bio' is problematic, since it insinuates that the ethical problems in health care are mainly arising from biological advancement and not from human and social relations.
Therefore, I propose to classify ethics of health professions into two main areas, bio-medical ethics and professional ethics. Bio-medical ethics can further be classified into medical ethics and bioethics. Medical ethics deals with problems arising from relationships between patient and health professionals. Confidentiality, prohibition from having sexual relationship with patients, principles of beneficence and non-maleficence are examples of medical ethics. Bioethics deals with problems arising from scientific and technological advancement. Changing concept of being a human is the main topic of bioethics. Philosophical debates concerning cloning, end of life problem and stem cell research are examples. Professional ethics, on the other hand, deals with social relations among profession, the public and the government.
The literature on bioethics or medical ethics, however, pays very little attention to professional ethical problems. Very often professional ethics is simply relegated to sociology of medicine, with which many ethicists are unfamiliar. Then why we should refocus on professional ethics? That's because expectations of both the profession and the public have changed a lot since the introduction of modern biomedicine. Doctors' general strike in 2000 Korea is an example of the conflict between expectations of the profession and the public. The public expected doctors to be beneficent caregivers regardless of social structural and economic situation. The profession put their self-interest first, however they claimed to serve the public. Moreover, the two groups seem to have different knowledge claims over the problem of health. The medical profession has the scientific concept of health whereas the public tends to have commonsensical or alternative concept of health. Therefore we need to approach this problem from not only social but also moral and cultural point of view.
In order for us to resolve the conflict, we need to understand the nature of the contract established between the public and the profession first. The nature of this kind of contract inevitably reflects cultural background and historical experience of a given society. Korean society is well known to have gone through dynamic social and cultural transformations since the introduction of western civilization, of which biomedicine is important part. But the heritage of traditional East Asian culture has not died out. Thus, Korean society exemplifies mixed culture where traditional and western values are admixed and coexist. Religiously, Koreans have three different but inter-related traditions of Confucianism, Taoism and Buddhism whereas the western value system is based on Hellenism, Judaism and Christianity.
Morally, westerners put emphasis on transcendental values that enforce humans to do the right thing. Disclosing patient's secret, for example, is not good and therefore prohibited. There are preset values and prescriptions for morally right behavior. Ten commandments are prominent examples of the deontological moral prescription. There is another tradition where the purpose rather than the preset imperative is important. This teleological tradition constitutes an important part of our moral discourse too. In medical practice, for example, there are many ways to serve the needs of the body and the purpose itself is more important than any specific action done for the body. In both deontology and teleology, the good can be objectified in a rational way.
In East Asian tradition, however, the good is hardly objectified. The good is only revealed through a person who embodies and practices it. The aim of ethics is not to find objective values and then apply them in practical situation, but to realize and embody virtues in one's own mind. The moral good is to be realized and actualized in the process of cultivating virtues and not to be found objectively. In traditional Korean culture, therefore, good medicine is no more than virtuous doctors.
However, Korean medicine has been going through modernization process. Accordingly, not only the content of medicine but also the social structure and cultural milieu through which medical service is delivered have changed. The image of doctors has changed from Confucian virtuous scholars to smart scientists who know exactly what to do. Unlike their European and American counterpart, their potential competitors, i.e., traditional doctors, were simply excluded from the market by the government rule and not by their own effort. As a result of this, Korean doctors cannot be said to have fully accomplished professionalization process.
On the other hand, European and American doctors had to survive on their own, in highly competitive market where lots of different therapists were competing. Among many treatment modalities, biomedicine was the most successful thanks to the power of science it claimed. But the power of science was not enough. They also needed moral superiority to get people's confidence. So they drafted code of ethics and professed their mission of altruistic service. It was a kind of moral contract between the profession and the public in which altruistic service and moral confidence were exchanged.
Because of the differences in cultural background and historical experience, it is not reasonable to apply professional ethics of European or American origin to Korean situation without consideration of cultural background and historical experience. We need our own model of professional or occupational ethics.
In order for us to construct our own model of professional ethics, we should take the cultural and historical experience into full account. We have mixed images of doctors. In East Asian tradition, doctors are considered to be Confucian intellectuals who have embodied the art of humaneness. In western tradition, doctors are scholars who have professed Hippocratic oath and served the public in return for the noble prestige. In modern times, however, doctors are considered to be scientists who deal with hard facts of the body rather than value-laden human relations. Moreover, medical practice tends to be regarded as a profitable business. Then professional ethics is only a type of business ethics. But can we fully agree with this? Is there any other way to combine these traditions into a consistent moral idea? Let's try to do this.
Professional ethics consists of three components: moral contract, social contract and doctors' etiquette. Doctors' etiquette is simply manners according to which they are expected to behave. It was devised in the beginning of professionalization to separate themselves from marketplace charlatans and enhance their social status. They began to form their own culture. Basically it was inner circle ethics rather than norms conforming to the society at large. The main purpose was to guarantee their own interest by excluding unqualified practitioners from the market. As a consequence, however, the public interest was secured too. Here professional interest and the public interest coincided, and a kind of social contract was made. In this contract, long intensive education and hard work were compensated with enough remuneration. This contract does not seem to be so different from any other employment contract, where mutual interests are sought and met.
However, some have noticed that health services are not the same as craftsmanship because they serve for more fundamental human needs. They tried to incorporate the spirit of Hippocratic oath into the social contract, and have devised a conceptual model. In this model, moral values, not commodities, are exchanged. Doctors profess to serve the public and the public pays respect for their altruistic services.
Now it can be said that doctors have made dual contracts with the public; social and moral. If one emphasizes moral contract he or she becomes a professionalist trying to get involved in altruistic services. And if one emphasizes social contract he or she becomes a unionist trying to raise his or her own interest. But the two components are not mutually exclusive, just like yin and yang are mutually inclusive. If you try to fully actualize the professionalistic ideal you may starve. If you try to ignore the moral aspect of the contract, you may lose your own interest as well, because your clients may find you commercially oriented and leave.
The strike of doctors in 2000 Korea tells us that Korean doctors are prone to be unionists rather than professionalists. And I suggest that it is time to make a balance between the two. But this time we need our own model that is different from professionalization. Professionalization takes the moral contract for granted. But Korean doctors have not gone through the process. So it is up to them whether they make new moral contract with the public or be satisfied with being unionists. If they want to make a new contract, they need to understand what the public wants them to be, and what doctors want themselves to be.
Generally it can be said that the public want doctors to be healers, care givers and fair arbiters in complex situations, whereas doctors want themselves to be scientists and want to make decisions autonomously according to scientific facts only. Therefore we need to approximate the two different expectations. It may be easier for doctors to adjust their view into the public's rather than the other way round. I suggest doctors to suspend their alleged right to autonomy in order to reach an agreement with the public. Once they get the confidence of the public, they will be awarded not only autonomy but also more wealth and prestige.
In order to get the confidence, five key roles of doctors suggested by WHO would be helpful. First of all, doctors should be care providers rather than treatment deliverers. Second, doctors make decisions for patients. But the decision should not be made paternalistically. They should respect patients' autonomy too. Third, doctors should be efficient communicators both with patients and society at large in order to make right decisions. Fourth, they should be leaders and advisors of communities they belong to. And finally, they should manage both financial and human resources efficiently.
Korean doctors had not been actively involved in social activities even when authoritarian governments threatened their own interests. In 2000, the repressed yearning for professional autonomy broke out. But their argument was not supported by public opinion. And this lack of support was because there had not been moral contract between doctors and the public. So it is very important for Korean doctors to make a new moral contract with the public that is different from the one made by European or American doctors. In order to make satisfactory contract the following points should be considered. First, doctors should be actively involved in many social activities. Safe environment, industrial health and traffic safety movements are examples which doctors should work on to enhance general health status and also to get trust of the public. Second, doctors should have generally agreeable moral values that they are striving for. They have to decide whether they really want themselves to be professionals who have heavy responsibility as well as autonomy or they only want fair sharing of social wealth. If they want to be professionals, then they have to consider human values to resort to, whether it is eastern art of humaneness or western professional altruism. Third, in order to find proper value system to resort to, they have to understand people's cultural experience and understanding.
As Max Weber argued, the development of capitalistic economy was possible because protestant ethics had backed it up. Likewise we could argue that the prosperous medical practice will be possible only by establishing proper professional ethics based on moral contract between professionals and the public.