A Case Report from Turkey
- Mebrure Deger, M.D., Hanzade Dogan, M.D.
Istanbul University, Cerrahpasa Medical School, Department of Medical Ethics and Medical History,
Atakoy 2. kisim K-41 D-7 Istanbul, TURKEY
Eubios Journal of Asian and International Bioethics 11 (2001), 74-75.
There is no single universally accepted definition of clinical ethics.Among many a definition has been proposed by La Puma as follows: "Clinical ethics is the process of identifying, analyzing and resolving moral problems of a particular patient's care. The primary goal of clinical ethics is to improve patient care with bedside assistance. Clinical ethics seeks to improve the relationship between the patient and the clinician and the relationships among patient, family and hospital."
This definition has much in common with our approach for the real case we wish to present. We will try to analyze and resolve this case brought by the gynecologist to us, from the point of view of medicine, ethics, and law; while considering socio-economic elements.
Key Words: case, ethics, law, socio-cultural factors, medicine
In the middle of the night, a 17 yearold single girl (individuals below 18 year of age are not accepted as adults according to Turkish civil law) who was dressed in tight fitting trousers and a loose-fitting shirt came to the emergency clinic, together with her mother, her elder sister and the sister's husband. She was suffering from acute abdominal pain.The surgen, who met them was a friend of her sister's husband.
The surgeon, after examining the unmarried girl realized that her abdomen was swollen, and he thought she was either pregnant or had an ovarian cyst, and decided to consult with a gynecologist. According to the gynecologist's examination, the girl was a virgin but pregnant and the heartbeat of the fetus was noted by two doctors. After a short while the young girl gave birth but she looked very much astonished.
She told her doctor that she didn't know she was pregnant.Then the doctor asked her, " Did you ever go to a gynecologist or didn't you get suspicious that you were pregnant?"
She answered him; "After I coudn't menstruate for two months, I went to a gynecologist, and I said to him I am a virgin, and I don't want the gynecologic examination. In Turkey, traditionally most girls remain virgins until they get married. According to local morality, it is important to be a virgin. The doctor gave me some medicine and I used them. But I still couldn't menstruate and I didn't go to the gynecologist until this evening when I came to this hospital with ventral pain."
"I ask you, please don't say anything to my father about this subject. Because my father has a cardiac defect.If he hears about this unpleasant case ; he might die."
The girl's family - her mother, her elder sister and her sister's husband- have been waiting in the waiting room impatiently. The surgeon who examined the young girl first, and is a friend of her sister's husband, reveals to his friend about the secret. At that moment, the family is very astonished and worried, and they ask the doctor not to say anything to the father about this secret and not to show the baby to the young girl because she could give harm and may kill the baby.
Finally the doctors didn't show the baby to the young girl. The family didn't tell her father about the secret. The baby was left to a state institution by the girl's family's decision.
a) The young girl came to the emergency clinic with appendix pain.She was first examined by a surgeon and the surgeon consulted with a gynecologist. As a result, the abdominal pain was identified to be delivery pain.
b) This pregnancy was not followed by a gynecologist.
a) The situation has been revealed to the sister's husband by the surgeon who examined the young girl, first.
According to Turkish Medical Ethics Regulation ( Deontological rules) 1960; articles 4 and 14; the rule of confidentiality has been overridden.
Article 4: A physician or dentist cannot breach the confidentiality of a patient unless he is forced to by law.
Article 14: A physician or dentist must give necessary care to their patients. If he cannot save the patient's life, the physician should at best try to decrease or stop the patient's pain and misery.
A physician or dentist should give hope to their patient.If he believes that the bad news about the prognosis of the disease does not worsen his patient's condition, he should tell the truth openly in order to take proper precautions. However, it is recommended that the physician should not tell the patient about a potentially fatal outcome. A hopeless prognosis may be hinted with great precaution. Such a prognosis may be revealed to the patient's family if the patient did not ask for the prognosis not to be revealed.
The articles 24 and 25 of Turkish Civil Law protect personal rights. These articles explain confidentiality. In this case; according to these articles;
a) The girl is under 18,therefore she is not an adult. In this case the confidentiality of the girl has been revealed to her sister's husband by the surgeon.
b) If the birth is not legal (i.e.if the mother is not married if the father is unknown according to Turkish Population Law; the physician is obliged to inform the official authorities, but does not have to declare the name of the mother.
According to the article 198 of Turkish Criminal Law, if a person reveals confidential information which is obtained during duty and which is going to harm the person who confided, without a legitimate reason to reveal it, it is punishable with jail up to 3 months and fine. In this case; according to articles 24 and 25, the surgeon should not have revealed the situation to his friend.
a) The medical faculty graduation diploma Oath reads, "I will respect ( protect) the secrets which are confided to me ". In this case, confidential issue has been revealed to another person without consent of the young girl.
b) The secret subject has been revealed to the girl's family without being asked by the patient.
According to ethical principles; "Confidentiality" and " consent" are the elements of autonomy. The baby has been left to an association as separated from his family in order not to put pressure on the mother and the mother's family.
In this case, an innocent third party's, and the mother's lives are interfered in conflict with the principle of nonmaleficence.
After delivery, before revealing to the family for consolation, a psychologist could have been invited for the young mother, so that she could think about the situation and finally decide more thoughfully.
In this case, from the point of view of ethics, the element of "confidentiality" is highly significant from the moment the young girl has given birth, since the birth was illegal. The "secret" has been revealed to a third person - her sister's husband- by the physician without the patient's consent.
The young lady had not wished this situation to be explained to her father because it could even have a fatal impact on him. The physician respected her wish to a limited degree by not revealing it to the father, but obviously such a serious social event, which is not in harmony with traditional values, was revealed to the physician's friend (the young lady's sister's husband) by the physician, without taking any precautions (like calling a psychiatrist for the member's of the family and the young lady.) Thereafter, the sister's husband immediately revealed it to the other members of the family present except the father. The family's decision was to separate the baby and the mother forever to put an end to this unpleasent situation.
In this case, the description of confidentiality and the elements of secrets need to be clarified from the points of view of ethics and socio-cultural norms because they arose out of dilemmas of values. A puzzle of values and a conflict of expectations face us as it happens in many of the cases with ethical problems. The physician's not only revealing the secret to the father, but perceiving it to be harmless to reveal it to his friend without taking professional precautions (although it could have been a very pressuring social event for the other members of the family, as well) is the major point we have to focus on, because it ended up with the life-long separation of a newborn baby and mother without the mother's consent.
If we analyse confidentiality in this case from the point of view of ethics (values, expectations, identification of dilemmas) and traditional norms of behaviors, we must note the following: For Turkish society, values such as friendships (sharing the secrets) are very important. For that reason, the surgeon's revealing to his friend might be perceived as natural according to the social norms of behaviors triggered by the value of friendship. Therefore, it might not be perceived as a problem from the socio-cultural point of view.
Another point is that the surgeon might have, most probably, revealed this secret to his friend with the intention of protecting the patient and the integrity of the family, and finding a solution without having to inform the father.The value underlying his norm of behavior was most probably using his friendship to support the young girl. Also, this type of behavior is seen with paternalistic physicians who, when socio-cultural factors dominate, tend to override patient's rights without any intention of harm.
However, from the point of discipline of ethics, identification of probable problems of ethics in the clinics, recognition of the conflicts of values of both patients and physicians and family members, and awareness of expectations before employing the traditional norms of behaviors may play a tremendously important professional role. If physicians get proper training of ethics and behavioral sciences, they might become capable of proper clinical decision making, as to how to act and behave vis-a-vis the patient and the other interested parties.
From the legal point of view, in the Turkish context, many medical mistakes have been analyzed under the civil and the criminal codes, but usually these prove inadequate for analyzing cases sufficiently.That is because, according to those codes, if obvious harms cannot be linked to mistakes through lawful reasoning, then they cannot be defined as crimes.However, this inadequacy might be overridden by creating "a body of health law" born out of considerations around the problematic issues of ethics and medicine arising from the recorded cases, rather than trying to create general dictates of civil and criminal law to identify the criminal and what constitutes a crime to solve the problems of a crucial service such as health. Finally,socio-cultural factors and social value judgements usually have a great impact upon norms of behaviors and decision making. As explained so far, values underlying traditional norms of behaviors may not be distinguished and clarified by the desicion makers so easily, causing maleficence and lack of communication, i.e. friendship as a value might express itself as revealing a secret in the traditional norms of behaviors. Health regulations in this context, may remain inadequate to bring solutions to the problematic cases in clinics.Nevertheless a proper education of ethics and behavioral sciences for the health professionals,together with analyses of cases and evaluation of the feedbacks from the cases, might contribute to the recognition and resolution of value problems and contribute to the constitution of a problem sensitively, comprehensively, and guiding health law.
We gratefully acknowledge Ahmet Dogan M.Sc.for reviewing the article and for the critical comments he made.
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