Deontological Lessons of the Good Samaritan in Contemporary Codes of Deontology
Gonzalo Herranz, department of Bioethics, University of Navarra, Spain.
X Internationallecture Vade et tu fac similiter. From Hippocrates to the Good Samaritan.
Pontificalcommittee on Pastoral attendance to Health Care Workers
Rome, November 23-25, 1995
Published in Dolentium Hominum, 31
On the obligation to attend in emergency status
On the duty not to discriminate and to treat everyone equally
On the commandment of medical benevolence
Let us imagine, for a moment, that the parable of the Good Samaritan were presented to us as a case to study and discuss from the point of view of medical deontology. The idea is not new. The parable has been used by A. Jonsen as an exercise in clinical casuistry to demonstrate the inevitability of rationing in medicine today. But let us leave aside the application of the parable to fantasy scenarios, and let us place ourselves in a medical ethics seminar aimed at students or young professionals in medicine or nursing.
We read the parable and ask them to try to identify, in the light of the ethical codes, the issues raised by the case and the lessons derived from the story.
His first finding could be that the parable is a paradigm of the good and bad behavior of man, and in particular of the health professional, in an emergency status . If any of the participants in our seminar had some knowledge of general law or professional law, they could add that, in contrast to the exemplary behavior of the Good Samaritan, the behavior of the priest and the Levite constitutes today, in many countries, a crime of refusal of assistance, punishable by modern penal codes. The obligation to help in case of emergency is the first deontological lesson of the parable.
If any of the participants in the seminar were attentive readers of the Gospel and knew about the tense relations in Jesus' time between Jews and Samaritans, two communities that fiercely despised each other because of their ethnic and religious differences, they could make some very timely comments. It would tell us that this is not a standard case of emergency care. The parable is an eloquent plea for overcoming, in evangelical love of neighbor, misunderstanding and ancestral hatreds. Professional ethics also commands us health care workers to serve all patients with the same dedication and skill , regardless of their condition: the second ethical lesson given to us by the Good Samaritan is to refrain from discriminating among them.
Let us suppose that another of those analyzing the case not only reads the Gospel text: he is also interested in the introductions and footnotes in his annotated edition. He knows that the author of the story is the physician Luke. And he can legitimately imagine that the hagiographer Luke, while writing the inspired book faithful to the dictates of the Holy Spirit, cannot help but remain a doctor and inevitably projects his personality in what he writes, he projects himself as a doctor in the figure of the Good Samaritan. Our student deduces, and he is not without reason, that the Good Samaritan was, in reality, a good doctor. His gestures show it: his human heart is moved to compassion. leave his saddle, and acting like a good professional, he examines the wounds, evaluates the clinical status , extracts bandages, balm and wine from the bag he always carries with him, and practices the first cure. He puts the wounded man in a condition to be moved, puts him on his horse and takes him to the nearest shelter. There he accommodates him and takes care of him all day and perhaps even at night. The story of the Good Samaritan teaches us a third deontological lesson: that of medical benevolence, the affection of the doctor for the wounded and the sick.
Only the next day, when the favorable prognosis is confirmed, the Good Samaritan, after giving the innkeeper precise instructions on the care to be administered to the wounded man, advances him some money for immediate expenses, and leaves, promising the patient that he will return to see him when he is back, and the innkeeper that he will compensate him for the additional expenses. The Good Samaritan gives us a fourth lesson: the supererogatory duty to serve the patient gratuitously, and even to help him generously.
My task this morning is to show how the four lessons of the Good Samaritan have found a place in modern Codes of Professional Ethics. It is useful to know from the entrance that the mandates to attend in emergency status , not to discriminate and to provide loyal service are in a preeminent place among the general, fundamental obligations that must inform the total performance of the healthcare professional. The duties of benevolent friendship and altruistic financial aid occupy a marginal place in today's deontological rules.
On the obligation to provide care in emergency status
The obligation to attend in emergency status is present as a common rule in the Codes of Ethics everywhere, although the mandate is proclaimed with different emphasis and extension, according to the different countries and cultural areas.
It appears in the Codes of the Latin-Mediterranean area as one of the general principles of the physician's conduct. Thus, the oath to be taken by the Italian physician at the time of registration in the Professional Order includes the commitment to provide emergency attendance to any patient in need of it. In more detail, article 7 of the Italian Codice di Deontologia Medica, 1995: The physician cannot refuse to intervene and must, independently of his usual specialized activity, and in any place or circumstance, provide emergency assistance and care to anyone who needs it and promote in any case any other more specific and adequate attendance . The French, Spanish, Portuguese and Belgian Codes echo this and insist on the unavoidable obligation of all physicians to provide immediate financial aid to the injured, injured or seriously ill patient; they point out that this duty is incumbent simply because they are physicians and is independent of their specific professional function or specialized training .
In contrast, the standards in force in the Anglo-Saxon world are softer and more nuanced. Thus, on the one hand, the ethical guidelines of the British Medical association state that, In an emergency, all physicians are expected to offer to attend, but whether and to what extent they do so depends on the nature of the emergency; the possibility of obtaining more expert financial aid ; the more or less immediate threat to the patient's life; and the physician's willingness to undertake actions that are outside his or her usual clinical expertise. The Irish Medical committee 's guide to Ethical Conduct merely states vaguely that a physician must give financial aid in an emergency unless he or she is satisfied that alternative care will be available to the patient.
In the United States, the fear of incurring malpractice judgments for having administered unsatisfactory care to an injured or ill person at the scene of an emergency has had a significant influence on the physician's attitude. In accordance with the hard-line liberalism of American medicine, the Principles of Medical Ethics of the American Medical association do not establish the obligation to provide emergency care as a mandate per se, but rather as an exception to the principle that physicians are free to choose their patients. Thus states the VI of its Principles of Medical Ethics: In providing appropriate care to his patients, the physician, except in cases of emergency, is free to choose whom to attend [...]. Precisely because of the weakness of the professional-ethical mandate, several States have adopted statutes that they call "Good Samaritan Laws", by virtue of which physicians, nurses and, in some cases, ordinary people, who have provided emergency assistance at the scene of the incident, that is, outside the hospital or the physician's office, without the necessary instruments and resources, do not incur liability for their acts or omissions. It is surprising that, in the United States, the Good Samaritan appears on the scene of health emergencies at the hands of the law, and not that of professional ethics.
In the Jewish ethical tradition, there are no specific professional rules for emergency status . In coincidence with the Christian doctrine of the sacredness of human life, proper to the biblical tradition, it establishes the prevailing duty to preserve life, a duty that is imposed with such force that any legal rule that conflicts with that priority commandment is disallowed. The medical act of attending the one who is at risk of losing his life is sanctified, so that the physician does not have to do penance for not having respected the precepts that, such as the Sabbath rest, he may have broken in order to assist the wounded or sick person.
I have not found, in the Islamic Code of Medical Ethics, any reference letter to the obligation to attend in emergency situations.
At the international level, the position of the World Medical association should be cited, which is expressed in one of the clauses of the International Code of Medical Ethics (London Code of 1949), which includes among the duties of the physician towards patients this one: The physician, as a humanitarian duty, shall render emergency care unless he is assured that others are willing and able to give such care.
The ethical standards are finally completed by those that some associations of health professionals specialized in emergency services (nurses, resident physicians, laboratory technicians) have given themselves, which affirm the obligation in all emergency status to reverence life, to respect the dignity, autonomy and individuality inherent to every human being, and not to violate the patient's beliefs.
It is not easy to draw valid conclusions from this brief summary of comparative ethics. On the other hand, some problems worthy of discussion or research can be identified, such as the possible relationship between virtue ethics and rights ethics, proper to the Catholic and Protestant traditions, and the rules on emergencies in the countries belonging to these traditions.
It would also be interesting to study the history of how, in recent decades, older, more competent and experienced physicians have been transferring first emergency care to young physicians. What has weighed more heavily in that historical shift, the power of senior physicians providing themselves with a life less stressed by the stress and schedules of medical emergencies, or the need for a period in the training the young physician, tense and causing many growing pains, that provides the necessary psychological, professional and ethical maturity?
Let's move on to the second lesson of the parable.
On the duty not to discriminate and to treat everyone equally
The parable of the Good Samaritan is a plea for the universality of medical service. No one is excluded from it: neither the most hated enemies, nor the most despised neighbors, nor the victims of the most repugnant diseases.
Jesus wanted, in this parable, as in many others, to make use of pedagogical exaggeration to give his moral message the necessary force and thus overcome ancestral prejudices and hatreds. And an extreme exaggeration for the Jews of his time was to illustrate the commandment of love of neighbor through a story of charitable and sacrificial service that takes place between members of two ethnic groups that had elevated their mutual contempt to a cultural trait. That the victim was a Jew and his savior a Samaritan constituted an apodictic argument in favor of the thesis that there are no cultural, religious or political factors that limit the commandment of love of neighbor. This is a commandment of universal extension, and also very intense and strong. In our days it has gained new relevance when confronting the doctor and the nurse with patients infected by the acquired human immunodeficiency virus.
The most eloquent manifestation of the physician's and nurse's obligation to serve everyone equally is, in my view, this: there is only one professional ethic of health care, which is valid in times of peace as well as in times of war. This is stated, for example, in article 1 of the Principles of European Medical Ethics, promulgated in 1987 by the International lecture of Medical Orders: The vocation of the physician - it says - is to protect the physical and mental health of man and to alleviate his suffering with respect for the life and dignity of the human person [...] in time of peace as in time of war.
The deontology of the two equally honorable modalities in which the role of health agents in war has been expressed is clearly indicated: that of military doctors and nurses who have contributed to humanize armed conflicts with their dedication to heal wounded or sick soldiers and civilians; and that of those who, after estimating the enormous cost of pain and death that wars cause among combatants and, above all, among the civilian population, declare themselves pacifists, refuse to be part of the army, and contribute, in humanitarian missions, to alleviate the tremendous impact that wars have on health and human rights. Both proclaim that the Ethics of the physician is unique, the same, in time of war and in time of peace.
Moreover, since time immemorial, there has been a glorious tradition in the professional ethics of physicians of not discriminating: I do not ask you about your race, your religion, or your origin. I am only interested in your disease. The origin of this phrase is unknown, but it belongs to the oral tradition of medicine. The first written enumeration of the factors of medical non-discrimination is, apparently, the recommendation made by a Chinese doctor in the 7th century to his disciples: Bring comfort to the pain of every animate being, without worrying about his rank, his fortune, his age, his beauty, his intelligence, whether he is Chinese or foreigner, whether friend or foe....
A few months before the United Nations published its Universal Declaration of Human Rights, the World Medical association had included in its 1948 Declaration of Geneva the physician's pledge to Disregard political or religious creeds, nationalities, races, social ranks, and to prevent these from coming between my professional duties and my patient. To bring it up to date in this curious time of ours, the association resolved in Stockholm, in 1994, to reshape the clause, which now reads: I will not allow considerations of age, illness or disability, creed, ethnic origin, gender, nationality, political membership , race, sexual orientation, or social status to come between my professional duty and my patient.
From the Geneva Declaration, the non-discrimination clause has passed into all modern codes of medical ethics. The French Code of 1995, for example, states: The physician must listen to, examine, advise and care for all persons with the same conscience, regardless of their origin, their customs and family status , whether or not they belong to a particular ethnic group, nation or religion, their handicap or state of health, their reputation or the feelings that he [the physician] may have about them.
The Good Samaritan did not inquire into the background of the wounded man. He was, by all accounts, a Jew. But he was essentially, and above and beyond his nationality, a badly wounded man. He was inaugurating what would become the Christian tradition of health care workers identifying the sick, whoever they are, with Christ: a tradition that will last as long as there are sick people and will only end on the day when Christ himself will say to them before all men of all times: "I was sick and you came to visit me: what you did to them, you did to me".
On the commandment of medical benevolence
I am happy to say that the Charter for Health Care Workers of this Pontifical committee is included in its own right among the Codes of contemporary Deontology. It is, among them all, the one that deals most freely and profoundly with the solicitous and vigilant, trusting and open attitude that the health worker must adopt towards the person and the needs of the patient. It says, in language that unfortunately has long since disappeared from deontological prose, that to care for a sick person with love is to fulfill a divine mission statement that can only be motivated and sustained by a disinterested, available and faithful commitment.
Modern Codes of Medical Ethics have over-formalized the doctor/patient relationship. They treat it with a contractual, legal, bureaucratic mentality. They have made it an epidermal, technified relationship, which, in today's complex hospitals, can become anonymous, faceless. They have left aside what the old professional guidelines prescribed about the extent and deontological limits of the correct affective bond between doctor and patient, of their friendship, of the virtue of benevolence, which are the typical medical-nursing expression of the mandate of charity.
The deontological codes of Southern European countries retain, however, many elements of the virtue of medical friendship. The Code of Medical Ethics and Deontology in force in Spain includes among the ethical duties of the physician towards his patient that of giving his work a sense of service that is rendered with delicate respect, with application and loyalty, a service that has to take precedence over any other staff convenience, over any unjustified delay in his care. The Deontological Code of the Spanish Nursing adds to these duties the duty to protect the patient from any humiliating or degrading attention , from any affront to his staff dignity, to never use against him measures of physical or moral force. The duties of the nurse become more intense and detailed when the patient belongs to one of the vulnerable groups (handicapped, disabled, children, elderly) to whom special and qualified attention must be given.
Undoubtedly, good care by doctors and nurses to their patients cannot be done without some kind of goodwill, without an internal disposition of solicitous dedication, which is expressed externally in the punctuality and delicacy with which professional services are administered. It has been said in a thousand ways that to serve is to love. This explains, perhaps, why today's Codes speak of service, not love.
Today's codes are very sparing when dealing with the affectivity that can legitimately be established between healthcare workers and their patients. They treat the topic with the grave and severe tone used by the Hippocratic Oath, to prohibit the doctor or nurse from exceeding the limits that professional prudence imposes and that health equanimity demands. It is important to insist strongly on the physician's deontological obligation not to gratify himself erotically on the occasion of the professional relationship. The healthcare professional must maintain the necessary emotional distance from his patient, never going beyond what, since William Osler, has been called the "restrained love" of the physician for his patient. Frivolous or sentimental neglect of this rule has been the cause of many misfortunes. Nothing is more destructive and distorting to the doctor/patient or nurse/patient relationship than succumbing to the temptation of excessive intimacy, romantic romancing, flirtation, or sexual relations. The Code of Medical Ethics of the American Medical association 's committee on Ethical and Judicial Affairs states that sexual relationships between physicians and patients degrade the purposes of medicine, exploit the patient's vulnerability, obscure the physician's objective judgment regarding the care he or she should provide, and ultimately impair the patient's well-being.... At a minimum, the physician's ethical duty requires him to terminate his professional relationship with his patient before entering into any relationship with him (dating, romantic love, or sexual relationship).
Thus we come to the fourth and last lesson of the parable.
The supererogatory duty to serve the patient without receiving anything in return, even more, helping him with largesse.
This tradition has disappeared from the codes of ethics of countries that have a national health service with universal coverage. However, this is not the case in countries where a more or less large part of the population combines lack of health insurance with economic destitution. This is tragically common in poor countries. It is also strikingly common in the United States, where between 35 and 40 million human beings lack the means to obtain qualified medical care.
There, the tradition of benevolent attendance to the poor patient remains in force. The American Medical association 's Code of Medical Ethics states that all physicians have an obligation to engage in medical financial aid to the indigent [...] and to work to ensure that the needs of the poor in their community are met. Caring for the poor should be an ordinary part of the physician's regular program of work . [...] They can do this in many different ways: receiving patients in their office for no or reduced fees, providing free care in hospitals or clinics, participating in government programs that provide medical care to the poor, or providing services on weekends in charity offices or in shelters for the displaced or for battered women.
In the Codes of the countries of the European Union, only the so-called professional courtesy persists as a vestige of this ancient charitable tradition, the custom according to which the physician who is called to attend his colleague or a close relative of his colleague, Withdrawal professional fees, as a sign of friendship and as moral compensation for the trust that has been placed in him.
As we are well aware, the relationship between physicians and money is very complex. They have been stereotyped in the three-fronted Aesculapius, who is represented as an angel when he comes to cure the patient, as a god when he cures him, and who is transfigured into a demon when he demands payment of his fees.
The parable of the Good Samaritan has immeasurably enriched the precepts of the Hippocratic Oath, because in addition to the duties of scientific skill and respect for the human dignity of the patient to which the disciple of Hippocrates was bound, the parable imposes on the healthcare worker the supreme duty of charity: altruism, abnegation, non-discrimination, generosity. Fortunately, these duties, whether supererogatory or not, have been incorporated into the codes of professional ethics, or persist as uncodified mandates, influencing the souls of healthcare workers. Oath and parable have exerted, and will continue to exert, throughout history a synergistic effect on healthcare professional deontology.
May the permanent memory of the attractive figure of the physician who was the Good Samaritan inspire our professional conduct. Pope John Paul II said it with the right words in Salvifici doloris: the health care worker is the Good Samaritan of the parable who approaches the wounded man and becomes his neighbor in charity.
Thank you very much.