A person who seeks medical care hopes for and expects intelligent, compassionate and ethical problem-solving skills from the physician. This expectation is grounded in the elevated behavioral norms to which physicians have held themselves going back in history at least as far as the Hippocratic Oath.
The spiritually and psychologically wide-ranging 12th or 18th century CE Prayer of Maimonides – historians dispute the date and authorship – revised and expanded upon that ancient oath.
In the wake of the gross perversion of medicine practiced by Nazi-German physicians and scientists, the international community produced a flurry of documents re-codifying the norms of civilized behavior: the Nuremberg Code of Ethics on Medical Research (1946), the UN Declaration of Human Rights (1948), the UN Declaration of the Rights of the Child (1959), and two World Medical Association (WMA) edicts – the International Code of Medical Ethics (1949), which is broadly concerned with the duties of clinicians toward patients and colleagues, and the 1964 Declaration of Helsinki, (revised 2008), which regulates biomedical research involving human subjects.
Today in Israel, several law codes regulate the interrelationships between healthcare providers and patients: the National Health Insurance Law (1995), the Patient's Rights Law (1996), the Terminal Patients Law (2005), and rules published by the various healthcare professions (e.g., the Ethical Code of Nurses in Israel [2004]).
Rambam's Helsinki-mandated Clinical Studies Ethics (Helsinki) Committee, analogous to Institutional Review Boards (IRBs) abroad, is chaired by Prof. Moshe Berant, co-chaired by Prof. Amihay Rubin, and coordinated by Ms. Dolly Haddad. "I want physicians to understand that their seriousness toward biomedical research is reflected in the care and seriousness of their observance of regulations when submitting documents to our committee," Prof. Berant says. "This is an ethical process, not merely a bureaucratic procedure in the derogatory sense; the analogy would be well-kept clinical files." The committee's careful vetting of more than 30 proposals submitted monthly reflects Rambam's emphasis on clinical research excellence.
Two additional, Patient's Rights Law mandated instruments are the Medical Ethics Committee, composed of physicians and public individuals and chaired by prominent Haifa attorney Yaacov Gilat, and the office of Ombudsman for Patient Services, held by Emeritus Head of Internal Medicine and Gastroenterology Prof. Shmuel Eidelman. "[RHCC Director General] Prof. [Rafael] Beyar really is interested in total transparency," Prof. Eidelman remarks. "He has been tremendously supportive of my own belief that we need to be transparent and honest and change when change is needed."
A number of other, voluntary forums attest to the vitality of Rambam healthcare professionals' engagement with the practical ethical dilemmas confronting them in their daily working lives.
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"We want as many relevant parties as possible to be involved in our committee's decision-making process because our secondary goal is to bring ethical issues to the surface, to expose them and thereby educate healthcare professionals' thinking process."
Gad Bar-Joseph, MD
Director, Pediatric Intensive Care, RHCC
Chair, Advisory Ethics Committee
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The Advisory Ethics Committee (est. 1996) was originally conceived by attorney and University of Haifa based philosopher Gershon Grunfeld, PhD, LLB, and Ms. Roni Gagin, Director of the Social Work Department at RHCC, and is chaired by co-founder Dr. Gad Bar-Joseph. Whereas Rambam's statutory Medical Ethics Committee addresses a specific and limited category of cases (e.g., administration of treatment to a patient incapable of informed consent), the AEC tackles a far broader range of medical-ethics quandaries. Over the years, it has delivered seventy carefully weighed recommendations, the majority in response to dilemmas regarding the high-tech prolongation of life.
The Medical Ethics Study Forum (est. 1996), also chaired by Dr. Bar-Joseph, convenes monthly and brings together approximately 25 physicians, psychologists, lawyers, social workers and ethicists. It was initiated by Specialist in Internal Medicine Prof. Rosalie Ber and late Professor of Internal Medicine Gidon Alroy.
The University of Haifa based, Rambam affiliated Center for the Study of the Doctor-Patient Relationship (est. 2003) is the brainchild of RHCC Ombudsman Prof. Shmuel Eidelman, who also chairs the Center and delivers an elective in the Masters of Public Health (MPH) program. …………………………………………………………………………………………
"Our forum aims to empower the nurses by providing them with ethical decision-making simulations so that at the moment of clinical truth, they have the competence and maturity to express their professional conscience."
Pnina Dagul, RN, MA
Coordinator, Nursing Staff Training and Development, RHCC
Chair, Nursing Ethics Forum
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The goals of the Nursing Ethics Forum (est. January 2009) are to increase the nurses' awareness and sensitivity regarding clinical-nursing ethics, to provide them with a resource for coping with ethical conflicts, and to strengthen the leadership skills necessary for conducting ethical discussions among colleagues. The pilot project's 27 participants, handpicked for leadership qualities and including representatives of each of the Nursing Department's 9 divisions and 21 units, have received training in a process-oriented model of ethical decision-making pioneered by Dr. Nurith Wagner, Chair of the Israeli Nurses Ethics Bureau.
Events
Throughout the year, Rambam hosts a large number of international, national, campus-wide and departmental events that speak in whole or in part to ethical dilemmas relevant to healthcare professionals' daily working lives.
On December 18, 2008, for example, guest speaker Mr. Kassim Baddarni, Director, AL-TAJ for Health and Heritage, presented a lecture to Senior Staff entitled Medical Ethics According to Islam. He spoke of Muslim attitudes toward sickness and the medical implications of Islamic law's categories of personal conduct (i.e., obligatory, recommended, permitted, discouraged and prohibited). "For instance, the Ramadan fast has a medical significance when giving a prescription," he said, and summarized, "Listen, observe, ask! Be aware of the patient's degree of religious adherence."
On March 3, 2009, in the context of the Northern Israel Annual Meeting on Pediatric Oncology, which was held on the Rambam campus and whose subject was Clinical Trials in Children, speaker after speaker acknowledged the special vulnerability of a hospital's youngest patients and therefore the extra degree of ethical sensitivity required of pediatric clinical researchers. For example, RHCC Department of Pediatric Hemato-Oncology Director Prof. Myriam Ben Arush and Clinical Psychologist Mrs. Elena Krivoy, in their joint case presentation, reminded a hushed international audience of oncologists, researchers, social workers and psychologists, medical ethicists and legal experts that "it is impossible for parents to be prepared for a cancer diagnosis. It generates a very high wave of emotional distress, and [the parents] are hit with complex information; at this fraught moment, the informed consent process begins."
And On June 26th, the Medical Ethics Study Forum convened to hear heart surgeon (and group member) Dr. Yaron Bar-El, Deputy Director and Director of Medical Operations at Rambam, deliver a presentation entitled Ageism and the Missing Bed that considered how age influences, often unjustly, decisions regarding allocation of scarce hospital resources. Participants discussed the ethical implications of such facets of geriatrics as the medical fact that some diseases behave differently in elderly and non-elderly patient populations, the methodological fact that most clinical trials do not include the aged and therefore research knowledge is lacking, the social reality (alluded to in the title of Dr. Bar-El's lecture) that decisions must be made regarding allocation of limited resources, and what one participant called "the symbolic aspect of the bed" as suggestive of a worrisome "stigmatization of the aged."