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In Colombia, dealing with death and technology.

In Colombia, Dealing with Death and Technology

Ever since Hippocrates inspired the medical profession with the noblest ethical values, the history of medicine has been interwoven with professional ideals, moral standards, and issues of conscience. This close association of practice and ethics is evident in Colombian medicine.

The first program of studies in medicine was formulated and implemented in 1801 by Fathers Jose Celestino Mutis and Miguel de Isla at the School of Medicine for the College of the Rosary. The program required five years of theoretical studies and three years of practice at the Hospital. [1] In 1817, Don Pablo Fernandez de la Reguera, a Spanish doctor and apothecary, founded the Academy of Medicine and became the first person to hold the chair of medical ethics. He taught classes to those who would exercise the noble art of Galen, competing with the deafening sounds of the bugles and drums of the Wars of Independence in 1817. The fact that the chair of medical deontology in the School of Medicine was always filled during the nineteenth century is evidence of the importance attached to ethics by physicians and professors of the time.

Prior to World War II medical practice in Colombia was heavily influenced by Frency physicians and techniques. Since that time more attention has been given to the advances and practices of North American medical science. This influence helped Colombian medicine to realize advances within its own milieu that had never before been attained.

Diminished Professional Responsibility

Yet, in the last few decades there has occurred a deplorable loss of ethical values in the practice of the medical profession. Several reasons for this decline can be enumerated: the increasing costs of highly specialized medicine, the socialization of medical services, and the tendency to form trade union syndicates, as well as the individual style of practice of many doctors. Colombian physicians recognize and lament this downward slide, but it is hospital patients who have suffered the adverse consequences of this decline.

Medicine by its nature demands professional responsibility. The physician cannot evade responsibility for the human beings under his care: decisions must be made regarding health, life, and existence. In recent years, three developments in Colombia have given hope that responsibility will be renewed in the practice of professional medicine; they represent as well important moments in the history of Colombian medicine and in the advancement of medical ethics in Latin America.

Professional Codes and Programs

Code of Medical Ethics. In 1981, Law No. 23 established the first Colombian Code of Medical Ethics, indicating that medical practice is to be supported by the demands of traditional moral values. The Code is legally binding on all physicians who practice medicine in the country. In addition, its Article 47 mandates the teaching of ethics in all twenty-one of Colombia's schools of medicine.

Medical Ethics Program of ASCOFAME. The Colombian Association of Schools of Medicine (ASCOFAME) was founded in 1959 to oversee the interests of the various schools. It has created its own organization, Program for the teaching of Medical Ethics and Bioethics, to assist medical school deans in implementing Article 47. It is expected that within approximately three years all prospective medical professionals in Colombia will be receiving ethics education, based on the maxim: "Science without conscience can only lead to the downfall of the human being." [2]

Institute of Bioethical Studies. In 1985, a select group of professionals from different departments at the National University, Bogota, met under the leadership of Dr. Fernando Sanchez-Torres and initiated the Colombian Institute of Bioethical Studies. Its fundamental conviction is that both medical investigation and the practice of the biomedical sciences require criteria, values, and ideals.

Major Bioethical Issues

Termination of Treatment. Currently, the principal bioethical question in Colombia concerns the prolongation of life for the dying. Within the city of Bogota, twenty lectures and panels have been held on this issue alone in the last two years. As in so many cases, the problems have emerged from the very advances of the medical sciences. Since World War II, emergency receiving rooms and intensive care units have multiplied in hospitals in Bogota and other major cities. [3] While their presence has undoubtedly produced many great benefits, they have at the same time created the possibility of unnecessarily prolonging the process of dying for terminally ill patients.

The general response of the Colombian medical profession to this issue has not been in the direction of euthanasia. Rather, the tendency in medical practice has been towards what some ethicists have called "disthanasia," which means the unnecessary prolongation of life by all means possible, in some cases against the wishes of patients and immediate family members. [4] This response is largely attributable to a belief in the imperative that doctors ought to use all the technological resources made available by advances in contemporary science and medicine to prolong the lives of their patients. The consequences of this conviction are well known: high costs of hospitalization, inefficient use of economic and human resources and technical equipment, and discontent on the part of patients, their families, and society at large.

In 1979, the Foundation for the Right to Die with Dignity (Derecho a Morir Dignamente [DMD]) was established in reaction to the phenomenon of disthanasia. The Foundation was not established to critique medical advances or the continuous praiseworthy efforts on the part of physicians to save human lives. Nor does it condone any form of euthanasia, to which it is completely opposed. Instead, DMD is concerned with promoting the right to die with dignity as a natural right possessed by every citizen amd with defending patients against a domineering medical practice. A complementary organization called Omega was recently founded to educate patients about their righ tto die with dignity and to provide counseling to them during the final phase of life.

Organ Transplantation and the Definition of Death. In the area of organ transplantation, Colombia is one of the most advanced of Latine American countries. In Medellin, Colombia's second largest city, St. Vincent's Hospital and the Cardiovascular Clinic have performed hundreds of kidney and bone marrow transplants, as well as five heart and three liver transplants. [5] Yet organ transplantation has raised its own ethical issues, particularly regarding the determination of death. Some physicians have objected that organ procurement risks taking organs from persons who were not yet dead, and jurists have noted that taking organs from still living donors violates the law.

This controversy has its roots in a 1980 decree (No. 2642) by the Secretary of Health that regulated Law 9 of 1979, whose Title IX deals with the transplantation of human organs and tissues. The Decree created an unfortunate confusion because the distinction between "organic" and "cerebral" death was not clearly articulated. The result was that cerebral death could be identified with organic death.

In turn, this produced an impasse: How could any physician or surgeon remove the organs from an "organically dead" donor? Doctors were quite aware that the success of organ transplants depends on acquiring "living" organs, but by the 1980 definition of "death," total death of the donor would have to be verified before the organs could be removed. Acquiring the organs before such verification would seem to violate both the law and the norms of medical ethics.

A new Decree (No. 2363), promulgated by the Secretary of Health in 1986 and superseding the 1980 decree, partially regulates Title IX by making a substantive substitution in the text of Law 9 of 1979. The new decree allows a determination of death to be made when a patient manifests irreversible absence of "all functions in the encephalic area." Proper diagnosis of cerebral death must be made before organs can be retrieved for transplantation or other therapeutic use. A doctor may declare a patient brain dead when absence of spontaneous respiration and of "all reflect in the encephalic area" is demonstrated on three examinations conducted at intervals of not less than twelve hours.

This concept of cerebral death is compatible with preserving the functions of vital organs through the use of artificial methods of respiration. In other words, cerebral death now cannot be confounded with total, organic death throughout the body. The new definition of death resolves the legal and ethical objections to organ transplantation, and it is now hoped that the number of organ transplants will continue to increase in Colombia.

References

[1] Andres Soriano-Lleras, La medicina en el nuevo reino de Granada durante la conquista y la colonia (Bogota: Universidad Nacional de Colombia, 1986), 161.

[2] Instruction on Respect for Human Life and the Dignity of Procreation (Rome: Congregation of the Faith, 1987).

[3] The first intensive care unit in Colombia was established in the Shaio Clinic, Bogota, in 1959 by doctors Fernando Valencia, Eduardo Garcia, and others.

[4] Among others see Marciano Vidal, Moral de la persona (Madrid: Ed. Perpetuo Socorro, 1985), 5th ed., especially discussion of disthanasia, 280ff; and 277, n. 96.

[5] El Tiempo, October 28, 1987, 1C.

Alfonso Llano-Escobar is professor of ethics at the Xaverian University, Bogota, Colombia.
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Title Annotation:Special Supplement: International Perspectives on Biomedical Ethics
Author:LLano-Escobar, Alfonso
Publication:The Hastings Center Report
Date:Aug 1, 1988
Words:1509
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