- Ivan Segota, M.D.,
Professor of Medical Ethics and Medical Sociology, Medical Faculty, University of Rijeka, O. Ban 22, 51000 Rijeka, CROATIA
Croatia, one of several independent countries established after the disintegration of former Yugoslavia in 1990, now has its first ethical medical codex. Ethical codices passed in Yugoslavia were previously valid for Croatian physicians, and before that, ethical codices passed in Austro Hungarian monarchy to which Croatia belonged but without state independence.
After the dissolution of former Yugoslavia, the Yugoslav Medical Association that passed the ethical codex for all physicians in Yugoslavia in 1963, was also dissolved. That codex was at the same time assigned to all medical staff and not only to physicians. After Croatia gained its independence and became a member of the UN, Croatian physicians could pass their own ethical codex within their national medical association, the Croatian Medical Association - that was establised in 1874.
Background to the codex
First, it should be mentioned that the fundamentals of medical ethics in Croatia are quite old and nowadays are forgotten even among Croatian physicians. For instance, the first doctoral dissetation in the field of medical ethics that was written by a Croat dates from 1843, whereas the first such-like dissertation in Sweden dates from 1971, which is 128 years later (1).
Croatian physicians took the initiaitive to pass their first ethical codex on the occasion of the 25th anniversary of the existence of their professional association (1899). Until then they were using the Codex of their German collegues. The codex was a translation of a German brochure from 1876 and entitled: "The Medical Class and the Citizens" (2). Since January 1901 they have their own ethical codex entitled: "Main Principles of Medical Honor" that was passed during the annual conference of their national association (2).
However, at that time Croatia was a Kingdom within the Astro-Hungarian monarchy but with only two of Croatian regions (Croatia and Slavonia, without Dalmatia). Afterwards, Croatia was "benovina" (benovina is an administrative and territorial unit reigned by "ban" (person leading the unit) on behalf of the king) within the Kingdom of Yugoslavia, and in Tito's Yugoslavia it was one of six republics with limited autonomy. Since 1990 Croatia has gained its independance and international recognition, so that the medical ethical codex from 1992 can in fact be considered as the first Croatian medical codex.
Characteristics of the codex
One of the important characteristics of that codex is the effort to connect traditional Hippocratic ethics with "new medical ethics" which is defined by the term "bioethics" (3). For example: In the version of the Hippocratic Oath most frequently used it is written: "To consider dear to me as parents him who taught me this art; to live in common with him and if necessary to share my goods with him..." (4). In the Croatian ethical codex it is written that the Croatian physician "pays respect and renders thanks to his teachers for acquired knowledge, skills and education" (5). This one detail of Croatian medical codex resembles even more the old Hippocratic oath from 5th Century B.C. than its revised version from 1948, the Declaration of Geneva where it is written: "I will give to my teacher the respect and gratitude which is their due" (4).
Furthermore, regarding medical secrecy in the Hippocatic oath it is witten: "All that may come to my knowledge in the excersise of my profession or outside of my profession or in daily commerce with me, which ought not be spread abroad, I will keep secret and everything seen or heard by a physician but only the matters confided as secret ("I will respect the secrets which are confined in me, even when the patient has died") (4). In the Croatian medical codex it is written: "Every information a physician has acquired when he perfoms his duty is considered a medical secret. The physician is obliged to keep secrets even from the patient's family members, if it is a patient's wish, also after his death, except in cases when it is legally differeatly defined (5).
It is obvious that in both these cases the attitude to teachers and to medical secrets the Croatian medical codex completely follows Hippocratic ethical tradition. However, at the same time the codex comprises prescriptions with no foothold in tradition or the Hippocratic oath. For example, informed consent.
Informed consent as a bioethical notion was completely unknown for Hippocrates and his followers, so that it has not got a foothold in traditional Hippocratic ethics. It is of course a matter of interest that the patient's autonomy reached the position of primary importance no earlier than the last thirty years, connected with the establishment of bioethics. Here follows a passage from the Croatian medical ethical codex concerning the above mentioned.
"Consciousness and honour make physicians performing clinical trials (experiments) on patients present for consideration their examination plan. A compenent board has to evaluate it regarding its scientific justifiability and ethical acceptablity. A person involved in the trial should be thoroughly acquainted with the sense of the enterprise, with the expected benefit and possible damage, and afterward will be asked for patient consent. If that is not possible, due to sensible reasons, consent will be given by the examinee's representative. The right to interrupt the co-operation at any moment must be guaranteed for any examinee" (5).
As the notion of informed consent does not comprise only the consent to participate in an examination but also refers to problems of patient's agreement connected with medical treatment, it is important to consider that aspect too. Here follows what the codex says about it. "A physician will in a suitable way inform a patient both about the result of the examinations and about further most advisable ways of treatment, and give him necessary information appropriately in order to decide properly concerned or persons who are not able to decide by themselves, a physician will refer to the patient's parents or guardians, or if that is not possible, he will consult with other physicians" (5).
Abortion and euthanasia
Let's see how the CMA codex relates to the classical topics of medical ethics: abortion and euthanasia.
Abortion: In the first version of the codex this topic has been solved in a similar to that in the USA. Namely, as the Principles of Medical Ethics of the AMA "do not prohibit a physician from performing an abortion in accordance with good medical practice and under circumstances that do not violate the law" (6), so that the CMA code in first version also says the same, for abortion in Croatia is not prohibited by law: "Conditions for the interruption of pregnancy are determined by law. Each interruption of pregnancy that is not in accordance with the law is a serious violation of medical ethics". (former article 3.4.)
On the other hand it was written: "If the interruption of pregnancy or sterilization is contrary to the physician's conviction he can refuse his taking part in these procedures, with the exception of abortion already commenced which has to be comleted professionally in accordance with legal regulations". (former article 3.6.).
But in the final version of the codex from the year 1993 these articles were dropped, so that the ethical codex of CMA does not mention anything about abortion, although in the practice based on the previous moral norm the physician's right to his own conviction, some groups have been established in Croatia which refuse to take part in performing abortions, so that hospitals have already cropped up in Croatia that do not carry out abortions, and this is coordinated with the firm ethical attitude of the Roman Catholic Church (the dominant religion in Croatia) and its fight against abortion.
Euthanasia: In the CMA codex is written that each deliberate shortening of life is contrary to medical ethics and that when taking care of dying parients only "alleviation of suffering and pain is allowable". On the other hand, regarding the artificial prolongation of life, physicians are not only allowed to regard the patient's wish, they are indeed allowed to decide by themselves if the apparatuses have to be switched off in certain situations ("If a patient is not conscious, a physician will act accrding to his best knowledge and conscience." (Article 4.2.).
Finally let us pay attention to the treatment in the newest CMA ethical code of three key problems of modern medical ethics, or bioethics, for some authors, "new medical ethics" (3). These are: transplantation, clinical investigation and artificial insemination.
Transplantation: The Croatian physician is obliged to inform conscientiously every donor of tissue or organs assigned for transplantation, "to inform of the nature of intervention and its possible consequences" (article 5.3.). However, if a potential and active participant is already involved in the commenced process of transplantation he is forbidden to take part in deciding the cerebral death of a donor.
Clinical investigations: Only three paragraphs mention this topic if compared with the AMA Code of Medical Ethics including, as already mentioned, the medical obligation to give their investigatory plan to a competent ethical board and ask for the examinee's informed consent: the investigator's obligation to publish the investigatory results firstly in the professional sphere and afterwards in the public domain.
Artificial insemination: The topic is mentioned very negatively, and that in two paragraphs. The first one: Both partners should "understand" what kind of a procedure it is (it is not emphasised as in the AMA Codex that 'the perspective parents should be informed that any child conceived by artificial insemination is passed off as, and entitled to all the rights of a child conceived naturally"). The second one: It is prohibited "to develop surplus human embryos for research purposes" (Article 3.2.)
The establishment and contents of the new ethical medical codex should be considered with two facts in mind: firstly, that it is the expression of the new Croatian history starting from 1990 when Croatia was established not only as an independent country, but as a non-socialist country too. Searching for its own identity the new country reconsiders and reforms almost everything including medical ethics; secondly, in that process the authors of the new medical ethical codex did not have any scientific tradition in studying medical ehical (in Croatia medical ethics as an academic discipline was established only at one of two medical faculties not earlier than 1991), so that they found themselves in the gap between the old ethics and the new medicine. They found the way out by connecting one and the other, by connecting the traditional Hippocratic ethics and new bioethics.
Becuase of that, this codex displays certain controversies, indistinctnesses and understatements, but the development of medical ethics as a modern science and the academic discipline in Croatia will soon prevail.
However, if we compare this codex with all its defects with the Russian medical ethical code passed in June 1992, by which Russian medical ethics, at least in declarative sense, was almost reestablished in the tradition of Hippocratic oath as if nothing had happened in medicine in the last two and half thousand years (7), the CMA codex is more up-to date and shows that Croatian medical ethics is still developing and that it is turning from the past towards the future.
1. A Croat from Dalmatia, doctor Josip Deskovic wrote his dissertation in German entitled "Concering Physicians Obligations against the State and his bearers (Joseph Descovich, doctor der medizin, Inaugural-dissertation, Ueber die pflichten des arztes gegen den staat und seine mitmenschen, Wien, Gedruckt bei den P.P. Mechitaristen, 1843.) According to R. Ingemar B. Indafl, associate professor of philosophy of medical science at the Karolinska Institute, Sweden, the first doctoral thesis in Swedan on medical ethics was written by Clarence Blomguist in 1971. (Hastings Center Report, (July/August 1989), Special Supplement, p.30)
2. Medicinska Enciklopedija, Zagreb. (Croatia) p.38.
3. "The Birth of Bioethics", Hastings Center Report, Special Supplement, (Nov.- Dec. 1993).
4. A.S. Duncan, G.R. Dunstan, R.B. Welbourn, eds., Dictionary of Medical Ethics, London, Edition 1981.
5. Croatian Medical Association - Code of Ethics (1993)
6. AMA: Code of Medical Ethics, Current Opinions, 1992, p.3.
7. Tichtchenko, P. (1994) "Resurrection of the Hippocratic Oath in Russia" CQHE 3: 49+.