Berna Arda (Associate Professor, M.D., Ph.D.), &Serap Sahinoglu Pelin (M.D.),
Unit of Medical Ethics, Ankara Medical Faculty, Sihhiya, 06100 Ankara, TURKEY
As a treasure house of history and culture, Turkey is a country which is located at the junction of Europe and Asia. The nature of Turkey is a humanized landscape inseparable from culture. Through history this place has been sheltering a lot of civilizations which included both settled villages and city life. For nine thousand years these civilisations consisted of peoples of different origins, coming in waves, mingling with those already there, each time creating a new synthesis. Between 2000 BC to 1500 AD this landscape was the centre of the world scene. Today it is predicated upon the understanding of what took place on this landscape over the past four millenia, manifested in the ruins and monuments which decorate Turkey.
Efforts of modernising the state and society started during the 19th century. Initially reforms have been limited by institutions such as the Armed Forces, faculty of Engineering and Medicine. After the Turkish "Kemalisk" Revolution, Western forms of science, art and literature penetrated the culture and continued to flourish.
The parliamentary system in Turkey was introduced more than a century ago, following the Turkish Revolution at the end of World War I. Reforms to achieve fundamental and broad-based social and institutional change were initiated by Mustafa Kemal Atatźrk, the revolutionary leader and first president of the Republic of Turkey. Secularism and protection of democratic individual rights and responsibilities of all citizens by the law are the most important among these reforms.
One of the obvious achievements of the Republic has been the establishment of women's rights in the new social order. The Turkish women has been exalted symbolically throughout history as the mother figure and pillar of the family. Since the Akakurk reforms, women's role in social, political and economic life has expanded dramatically. By the early days of the Republic, well-educated women, particularly in the cities, have taken on active roles in the professions, government and business.
Every social and institutional change eventually leaves its mark on the landscape. The reforms of first half of the 20th century put Turkey on a course of accelerated modernization. careful measures ensured that culture and traditions continue to live and evolve. Although the changes in Turkey were well choreographed and significant, they were not of the order of magnitude that are occuring today.
The main bioethical problems of Turkey in the light of these historical, cultural and social background are: Organ transplantation: the first debates on legal and ethical aspects of this subject begun in the 1960s. According to the Presidency of Religious Affairs, organ and tissue transplantation are permissible by the rules of Islam.
"The law on the procurement, preservation, grafting and transplantation of organs and tissues" was passed by the Turkish parliament in 1979. This law describes the conditions of organ transplantation from living persons and corpses. According to this law, organ commerce and advertisement are prohibited. Donors must be over 18 years old and competency of donor is necessary. Informed consent is obligatory for this process and mentally incompetent person's organ donation should be refused. If the donor is married, the spouse must be informed. The determination of death is a decision of a team (one cardiologist, one neurologist, one neurosurgeon and one anesthesiologist). Doctors who determine the death of the donor should not be involved in the transplantation team. The legal regulations and religious rulings are very generous and permissive in Turkey, but recently there has been a draft law presented which contains some changes about organ procurement and transplantation (1,5).
Abortion: In the first years of the Republic of Turkey population growth was desired and abortion was banned. The Turkish Criminal Law defined it as a crime. The religious belief that it was a sin also supported this subject (2). But, with changing socio-economic and sociocultural circumstances, abortion has been legalised. In 1983 the law on population planning was declared which allows abortion up to the 10th week of pregnancy. After this time, it is possible if the mother's life is in danger or there is presumed danger in the next period of pregnancy or if the fetus will have serious disease. Informed consent is necessary for physicians. The current policy is to promote the approach that each family should have as many children as they can feed, care for, and educate. The sterilisation regulation defines this process and it can be requested by an adult if there is no medical contra-indication. Like organ donation, in the married case a consent form from the spouse is obligatory (6).
Drug research: There is a legal regulation (7) which contains the principles of research on human beings with drugs and chemical substances. The regulation clarifies points like the stages of drug research, qualifications required by the researchers involved, duties of the central ministry, local ethics committees, qualifications for membership, procedures necessary in working on new drugs, specifications for protocols of clinical research. The procedure of admission with this regulation required the creation of ethics committees in educational hospitals which do drug research. Nowadays most ethical committees of Turkey are dealing with ethical problems in biomedical drug research and work like ad hoc committees.
Confidentiality: Medical Deontology Regulations state that physicians cannot reveal confidentiality unless they are forced to do so by law. But when a doctor is appointed as an expert it is obligatory for them to answer all the questions. According to Turkish laws, some situations which confidentiality may be revealed are defined. For example, child abuse, certain infectious diseases, and cases where the patient gives consent (1,4).
Euthanasia: Both passive and active euthanasia are forbidden (1). It is punishable as murder. The Moslem religious beliefs are against euthanasia, but recently this concept has been discussed among different levels of society.
Genetics: There is no direct legal regulations on genetic engineering and genetic counseling in Turkey. But in accordance with the general tendency across the world, the embryo and fetus deserve the respect like a human person, and fetal tissue and organs may only be used for therapeutic purposes (2). Medical technology has helped us in determination of some defective fetuses before birth. Prenatal tests and ultrasound allow to screen for deformities. Recently there has been some efforts to prevent using the methods of sex determination during pregnancy for non-medical aims.
Education of medical ethics: Medical ethics education is in the curriculum of medical schools in Turkey (8). The course most related is Deontology which is usually taught in the first year of medical school but is also taught in the fourth year in some faculties. The curriculum has very limited time and a didactic feature. Lectures are generally presented in only one semester for undergraduate students, and unfortunately there is no time yet for small group discussions, case presentations or any other pedagogic methods during the other semester. The essential aims of medical ethics education are moral sensitization of medical students, and the development of ethical awareness or consciousness regarding to the value problems arising in different aspects of medical activity (3).
Bioethics Society: The Bioethics Society was founded in Ankara on the 28th September, 1994. The aim of this society is to contribute to the progression and development of bioethics and its education and to develop its relations with health professions and other disciplines.
The society suggests the meeting of those who are interested in, and contributing to, bioethics. Other aims: to provide an atmosphere for communication and discussion, and also to provide international communication; to develop programmes for licence and postgraduate education; to organise conferences, symposiums, seminars, congresses; to provide publications; to encourage and support the activities regarding the subject; to introduce the subject to the public consistent with these aims. The society also aims to provide closer cooperation among the members to warn the related departments when faced with unacceptable behaviours regarding bioethics, and faults due to disrespectful attitudes, and to inform the public when it is necessary.
In addition to the society there are some other nongovernmental organisations. The Turkish Philosophical Association established a bioethics section in 1990. The Turkish Medical Association is interested in medical ethics issues and founded an ethics committee in 1993.
Publications in Medical Ethics: General medical journals have accepted papers on medical ethics but the first journal devoted solely to these issues was the Turkish Journal of Medical Ethics, published three times a year (April, August, December) since December 1993. Articles do need an English summary, key words, references. The journal has an editorial board and also an advisory committee, and is peer reviewed.
Medical ethics and bioethics are new subjects in our country, and for that reason people are generally not aware of their ethical rights, and it is still not dealt with sufficiently or effectively in the media. We could conclude that there is "still a lot of work to be done".
1. Kiyak, Y. "Lectures on medical ethics", Marmara University No. 445, s. 63-65, 89, 104-109, Istanbul, 1987.
2. Oguz, Y. & Arda, B. "Bioethics in Turkey", BME 73 (Nov 1991), 13-17.
3. …rs, Y. "Teaching medical ethics in the subjunctive mood", BME 93 (Nov. 1993), 31-6.
4. Medical Deontology Regulation, 1960.
5. The law on procurement, preservation, grafting and transplantation of organs and tissues, 1979.
6. The law on population planning, 1983.
7. The regulation of research on human beings with drugs and chemical substances, 1993.
8. Pelin, S.S. & …rs, Y. "Medical esthetics from a historical and ethical point of view", EJAIB 5: 35-6.