University of the Philippines in Mindanao Recognition for 2016

Our ethical formation as doctors begins early. My ethics was greatly formed in college. It shaped my ethics in my responsibility as doctor to the society. Earlier this week, I was informed that I am being recognized by my college Alma Mater as one of the Most Distinguished Alumni of UP Mindanao for 2016. Below is what I had to say:

Salamat sa mga nagbigay ng parangal na ito. Pero ano nga ba ang ibig sabihin ng parangal na ito? Para sa akin, ang tanong ay ano nga ba ang puedeng magawa ng isang estudyante ng UP Mindanao 20 years mula ng kanyang unang  enrolment? Opo, 1996 po kasi ang aking student number.

Sa loob ng 20 years, dapat po sana ay graduate ka na. Dapat sana ay tapos ka na sa pag-aaral mo at ikaw ay may trabaho na para kumita at may sarili ka nang pera. Para naman hindi ka na hingi ng hingi ng pera sa mga magulang mo. Maawa ka naman sa kanila kung sa loob ng 20 years ay humihingi ka pa rin ng pera hanggang ngayon. “Ang makagradweyt at makahanap ng trabaho.” Ulitin ko. Ang makapagtapos ng pag-aaral para makahanap ng MAGANDANG trabahong magbibigay sayo ng MAGANDANG sweldo ay HINDI po tinuturo sa UP. Hindi rin po yan ang natutunan ko sa UP, kaya alam kong hindi rin po yan ang ibig sabihin ng parangal na ito.

Noong kami ay nasa PCA compound pa bilang mga estudyante, ang tinuro sa amin ay kung paano makitungo sa ating kapwa tao mula sa iba’t ibang antas ng buhay. Noong kami ay nasa Pahinungod at umakyat ng Diwalwal o sa Boys Town ay tinuro sa amin kung paano pahalagahan ang kapakanan ng iba higit sa sarili. Noong kami ay volunteer sa Eagle Center at binabantayan ang Agila sa Arakan Valley kahit may panganib, tinuro sa amin kung paano pahalagahan ang kalikasan. Noong kami ay dumalaw sa mga komunidad ng Mandaya, Bagobo at Tboli ay tinuro sa amin ang kahalagahan ng ating kultura. Noong kami ay naglakad sa lansangan ng Magallanes at Claveria, natuto rin kaming ipaglaban ang katarungan. Noong kami ay umakyat sa bundok ng Hamuigitan at noong nagsurvey sa Davao Gulf ay tinuro sa amin ang kahalagahan ng pagtuklas at pagsaliksik ng bagong kaalaman. Hindi po PAANO maghanap buhay ang tinuro sa UP.

Ang natutunan po naming ay paano maglingkod sa kapwa, sa kalikasan, sa Diyos at sa Bayan. Pagkalipas ng 20 years, ano nga ba ang puedeng magawa ng isang estudyante mula sa UP Mindanao? Walang iba kundi ipagpatuloy ang nasimulan at natutunan sa UP. Ipagpatuloy ang tamang pakikitungo sa kapwa, ipagpatuloy ang pagtulong sa mga nangangailangan, ipagpatuloy ang paghingi ng katarungan, ipagpatuloy ang pangangalaga sa kalikasan, ipagpatuloy ang pagtuklas sa bagong kaalaman, ipagpatuloy ang pagsulong ng kaunlaran, at ipagpatuloy ang paglingkod sa bayan. Opo, pagkalipas ng 20 years ay hindi pa rin po ako tapos sa pag-aaral dahil estudyante pa rin po ako sa UP. Pero salamat po sa pagkilala sa mga gawaing itinutuloy lamang natin.

At ang pagkilalang ito ay pagkilala rin sa mga katuwang natin sa mga gawaing ito… ang mga taong tumulong sa atin sa komunidad, mga lider ng people’s organization, Civil Society groups, mga nakatrabaho ko at fellow development workers, mga kaibigan kong nagbibigay suporta at panalangin (sana dagdagan niyo ang inyong donations), mga fellow Pioneers (sayang at wala ng UKLAS Mountaineers) mga naging guro ko lalo na dito sa UP hindi ko na po kayo iisa-isahin (pero especial mention kay Ma'am Novero na nagtiwala sa ating kakayahan) at sa mga una kong guro... ang aking ama at ina; ang aking pamilya na lagi kong kasama at higit sa lahat si Bathala.

Daghang Salamat. Padayon…

AMDG... To God be the Glory...

Effective Altruism and the Ethics of Helping Others through Medical Missions

Effective altruism has been a major concern about the ethics of helping others. The discussion has centered on whether the help we offer has the greatest positive impact to the world. It scrutinizes whether the intent to help others is a valid reason enough to use our resources in certain activity. Such is the ethical questions that needs to be addressed by organizations thinking of maximizing their resources to help others through a medical mission. Here are Six Questions that needs to be answered before you organize a medical mission:


1. Is the medical mission the best way to improve the health of the individual and the community at large?
Medical missions are useful when disaster strikes as the health care system is overwhelmed by the situation. Yet, in ordinary times there are existing health services that the government are offering. It might be more effective to help improve the existing health programs and services available in the community to have longer lasting impact in improving people's health and the community as well. It It is better to put your resources to a program that will provide the greatest benefit to most number of people.


2. Is the medical mission needed in the area?
Many medical missions are conducted in areas that do not match the resources available to the needs in the area. One group once went to a depressed squatters area bringing antibiotics expecting many sick children. They found many to be sick with tuberculosis but do not have the medicines for it. Because medical missions often address acute medical needs, the timing and the location are important considerations for this activities. Another location might benefit the most with what you have to offer.


3. Are the recipients the neediest people who need the service?
This question is related to the first. Medical missions are often limited in their resources. It becomes important then to ask who will receive these limited resources? Do we give these to members of the organizations only? Do we invite our family and friends? Do we cater on a first come, first serve basis? Or do we exclusively limit it to the poorest people who needs the help the most?


4. Is the "medical mission" helping the local health system?
Each locality has an existing health care system. In low-to-middle income countries (LMIC) like the Philippines, it might not be as effective as we want it. But are the medical missions we are conducting helping the system or are we competing against them? Check if there are local health centers and health workers in the area. It will be unfortunate to conduct medical missions without their participation. You might miss creating a bigger and lasting impact.


5. Is the medical mission highly dependent on donations?
Do you conduct the medical missions on a regular basis or only when the resources are available? How will this impact continuity of health care to the people? If the reason why the medical mission was done in the area is because medical services are really needed, what does it mean to provide only once in a "Blue Moon" health services to them or only when resources are available? Limited resources is better placed in programs with the greatest health outcomes for all.


6.  Is the group concern with the health of the people or are they just using it as leverage for their own purpose?
What could be the driving force for the medical mission? Some churches have conditions for the beneficiaries, they offer only medical services only after the beneficiaries have participated in a Bible Study by the group. Politicians leverage it for their election. Groups use it to promote their products. Or do they simply want to help improve the health of the most number of people regardless of nothing to gain in return?


Effective altruism does not question the intent of the people to help others. For many utilitarians like Dr. Singer, they question the impact and effectiveness of the help offered. Effective altruism, thus, puts into proper perspective how medical missions can effectively impact the health of the wider-community. Were the resources used properly? But for virtuous doctors, the question really is, can the medical missions effectively help me become a virtuous doctor? Are the medical missions the best venue in forming in me virtues that will make me an excellent doctor?  For Christian doctors, can these medical missions be the best way for us to achieve Christ-likeness? Will these activities form in me virtuous of magnificence? Do I practice generosity?

For in generosity, I am helping the best way I can to a person who needs me most.

Doctor and Other Health Professionals

I teach bioethics to medical students. One of the lecture topics we cover in our class is the relationship of doctors with other health care professionals. In our current medical practice, paternalism is no longer the prevailing practice. We recognize the role of other health care providers in the well-being of the patient.

If you are interested to know more on this topic, you are welcome to join us. Below is the link for the handout on the lecture on Doctors and Other Health Professionals.

Download the E-book here.

Ethics of Privacy and Respect for Other People's Property

I always teach my kids to ask permission before they touch other people's stuff. That is a basic value people learn early in life. So, one wonders if it is morally right for the BOC employees to check the stuff sent by nurses and doctors to their families and friends? 

Can I open this?

The Philippines is one of the top exporter of nurses and doctors around the world next to India based on the IBON data for 2014. The healthcare workers form the largest chunk of OFWs. They work abroad to provide for their families, families that they do not see often. Despite being physically away, these OFWs show their love and care to their family members with the gifts of love they send to them through balik-bayan boxes. As one popular courier tagline puts it "Ipadama mo sayong padala." Every balikbayan box sent is an expression of love from a lonely OFW healthcare worker.

The "expression of love" is ripped open by the Bureau of Customs employees before it even reaches the supposed recipient. Did the people in the Bureau of Customs ask permission from the OFW healthcare worker? Is it morally right to open other people's packages without their consent? Is it ethical to sort other people's property? Is it valid to rip open a "package of love" for suspecting something taxable inside? What happened to people's privacy? What happened to autonomy? What happened to respecting people's right?

Privacy is an ethical issue. Is it morally right to invade my privacy? Privacy is important for several reasons. Privacy is necessary to safeguard the freedom of individuals and groups. People have the right to keep private and personal matters from the public. If people have the right to privacy, it is morally wrong to violate that right. It is unethical to invade other's privacy and personal property. For the same reason, invasion of privacy is against the law. For example, when I go to the mall and the security guard wants to inspect my bag, the guard cannot just open my bag. That would be unethical. The guard would be violating my privacy. That is why, I would have to willingly open the zipper of my bag and allow the guard to take a peek and inspect what is inside. Only because I allowed the guard to check my bag was the guard able to do it. No invasion of privacy occurred.

The government is supposed to safeguard the people's right to privacy, not the one violating it.

However, we also know that privacy is not an absolute thing. We live in a society that requires us to share information to maintain order in our relationship with each other. Going back to our example, I cannot just refuse the guard to check my bag because of my right to privacy. If I do that, the guard can always refuse my entry into the mall. In the same way, the balik-bayan boxes need to have proper declaration from the OFWs sending them. It is the OFWs duty to honestly declare the contents of the package. We understand that the government needs some information from its citizen for it to be able to govern properly and execute their responsibilities well.

There should be a balance between the OFW's responsibility to share honest information and to the protection of it's right to privacy. One is not more important than the other. The government cannot also give lesser weight to either of the two. It would not only be unethical for the government staff to open packages without the owner's consent, the government would also be violating the people's human rights.

Let this not be another addition to the long list of human rights violation of the government to its people. How can I teach my kids to respect other people if they do not see their government respecting people too?

Can I back date a Medical Certificate?

My resident doctors have been asking me what to do if they have patients who request to backdate their medical certificates.

"Sir, I have several patients come in to request for medical certificate because they want to be excused for their absence. Given that it is true, can we help them be excused so they get their salary by backdating the medical certificate? Is this ethical or not?"

For the sake of ethical discussion and not considering the legal implications, do you think it is ethical or not?

Veracity is the ethical principle of truth telling. Deontologists will tell us that doctors are duty bound to be truthful in their actions. Utilitarians will argue to do the action that will benefit the most good to all. But what about the character and values of the doctor that they must exhibit?

Truthfulness is a virtue that humans, especially virtuous doctors possess. What then should a virtuous doctor do when faced with a similar situation where a patient asks him to backdate a medical certificate? A virtuous doctor is expected to be truthful and would not lie about the date written in the medical certificate. He might, however, truthfully put a remark that the patient may have been sick for several days covering the dates that he was absent.

How do you make an ethical decision?

How do you make an ethical decision? I always get this question from my students.

While researching for recent trends in ethical thinking, I came across the Ethics webpage of Santa Clara University. Here, I was reintroduced to this framework for ethical decision making. We have tried using this framework in the monthly Ethical conference we have with medical interns in a government hospital in Manila. What is good about this framework is that it allows the medical students to think ethically. During the conference, medical students engage with each other and discuss which ethical standards will guide them in making a decision. (Watch out for my next entry on their discussions.)

Here is another example of making an ethical decision.

Below is a useful guide for ethical decision making whenever you encounter ethical issues. 

 A Framework for Ethical Decision Making

Recognize an Ethical Issue

1.       Could this decision or situation be damaging to someone or to some group?

Does this decision involve a choice between a good and bad alternative, or perhaps between two "goods" or between two "bads"?

2.       Is this issue about more than what is legal or what is most efficient? If so, how?

Get the Facts

1.       What are the relevant facts of the case? What facts are not known? Can I learn more about the situation? Do I know enough to make a decision?

2.       What individuals and groups have an important stake in the outcome? Are some concerns more important? Why?

3.       What are the options for acting? Have all the relevant persons and groups been consulted? Have I identified creative options?

 Evaluate Alternative Actions

1.       Evaluate the options by asking the following questions:

Which option will produce the most good and do the least harm? (The Utilitarian Approach)

Which option best respects the rights of all who have a stake? (The Rights Approach)

Which option treats people equally or proportionately? (The Justice Approach)

Which option best serves the community as a whole, not just some members? (The Common Good Approach)

Which option leads me to act as the sort of person I want to be? (The Virtue Approach)

Make a Decision and Test It

1.       Considering all these approaches, which option best addresses the situation?

2.       If I told someone I respect-or told a television audience-which option I have chosen, what would they say?

 Act and Reflect on the Outcome

1.       How can my decision be implemented with the greatest care and attention to the concerns of all stakeholders?

2.       How did my decision turn out and what have I learned from this specific situation?

 This framework for thinking ethically is the product of dialogue and debate at the Markkula Center for Applied Ethics at Santa Clara University. Primary contributors include Manuel Velasquez, Dennis Moberg, Michael J. Meyer, Thomas Shanks, Margaret R. McLean, David DeCosse, Claire André, and Kirk O. Hanson. It was last revised in May 2009. - See more at: http://www.scu.edu/ethics/practicing/decision/framework.html#sthash.rMJW1mW5.dpuf

 

Doctors love their neighbor

It is love month and it is only fitting way to reflect upon one of the virtues of a doctor, love for humanity.

Compassion runs in the blood of doctors. It is innate. The reason kids want to become a doctor is to help the sick. At an early age, doctors are already compassionate for the other person's well-being. Simply, loving your neighbor. The Hippocratic Oath reminds us that. Even in research, doctors must love their patients - human subjects.

But there was a time when the other person's well-being was abused. There was a time when medicine did not show compassion and doctors could only watch helplessly. It was a time of war.

Do you know how to manage hypothermia - if a person's body temperature drops? Do you know how they came to know it?

Doctors made a "Freezing Hypothermia Experiment" in 1941. Here, a cold water immersion experiment was presided over by Professor Ernst Holzlohner and Dr. Sigmund Rascher .They were testing the effect of wearing a Luftwaffe garment to counter hypothermia.

What they did was shocking. One study forced subjects to endure a tank of ice water for up to three hours. Another study placed prisoners naked in the open for several hours with temperatures below freezing. Then, the experimenters assessed different ways of rewarming survivors. 

These freezing experiments researched on how long it would take to lower the body temperature to death and how to best resuscitate the frozen victim.

The human subjects were usually stripped naked. Then an insulated probe which measured the drop in the body temperature was inserted into the rectum. Imagine how painful that was. To top it all, the probe was held in place by an expandable metal ring which was adjusted to open inside the rectum to hold the probe firmly in place.

The human subjects were put into an air force uniform, then placed in the vat of cold water and started to freeze. It was learned that most subjects lost consciousness and died when the body temperature dropped to 77 °F (25 °C).

This is not how you show love for your neighbor. Harming others in the name of science is not a virtue of a doctor.

Such cruelty during the war led to the drafting of human research protocols.

After the WW2, several codes, declaration and guidelines have been written and set.

•         Nuremberg Code (1947)‏

•         Universal Declaration of Human Rights (UN 1948)‏

•         Declaration of Helsinki (WMA 1964, 1983, 1989, 1996, 2000)‏

•         International Covenant on Civil and Political Rights (1966)‏

•         International Ethical Guidelines for Biomedical Research Involving Human Subjects (CIOMS 1993, 2002)‏

•         Council of Europe: Convention on Human Rights and Biomedicine (1997)‏

Doctors love their neighbor. This is a virtue innate to all doctors. This virtue guides doctors to show compassion to patients and even to those subject to human research.