To be able to perform well the roles of a fivestar doctor, the family physician

must effectively apply the principles of bioethics. In his/her daily mundane task
as a health care provider, the skills in working effectively with the health care
team, patients, and their families, as well as in decisionmaking, require a deep
understanding of many ethical principles. Internationally, the World Medical
Association established medical ethics for physicians for that purpose. Locally,
the Philippine Medical Association (PMA), in cooperation with the Professional
Regulatory Board for Medicine of the Professional Regulations Commission, has
revised the Code of Medical Ethics for physicians.

In the competencies of family physicians formulated in 1983, 1998, and 2007,

knowledge, proper attitude, and practice in medical ethics was included. Thus,
one of the foundation courses for Family Medicine specialists-in-training is on the
essential components of medical ethics-both the knowledge and the practical
application of clinical ethical reasoning skills. A family doctor must be able to use
the principles as a guide to his/her conscience in choosing the right solution to
any given problem. Given a situation, he/she must clarify the issue, the
stakeholders, and the applicable principles.

Then he/she can choose the action most in line w'th his/her commitment to a
Supreme Being (Cod, Allah, Budd ha, etc.), oneself, the patient and his/her
family, and the communitv.

Issues and Concerns which may Influence Ethics

The Hippocratic Oath is the first universal oath for which physicians in all
countries have sworn by. As previously mentioned, there are international and
national codes of medical ethics. The national code takes into consideration local
issues and concerns. Thus, it consider Filipino values and characteristics of
Clinical Family Medicine as possrble influences for medical ethics.

Manson (2008) enumerated the characteristics of Clinical Family Medicine that

generate ethical problems. The list was contextualized for the Filipino setting.

1. The emphasis on the patient as a psychological being, presented in the

context of culture, family, and community.

2. The existence of social and cultural diversity in the patients population.

3. The involvement in decision-making processes of multiple stakeholders, more

than one of whom may be the physicians patient.

4. The interaction of the physician with vulnerable populations, such as minors

and the mentally disabled.

5. The physicians responsibility to manage the full spectrum of health

conditions.

6. The responsibility to provide personal care to a patient over a prolonged

period of time.
7. The inclusion of patients of all ages in the population.

8. The pressure of conflicting duties on the family physician due to a health care
system organization and changes to this set-up.

Definition 6f Medical Ethics

Medical ethics or bioethics is the study of moral issues in the fields of medical
treatment and research. The term is sometimes used more generally to describe
ethical issues in the life sciences and the distribution of scarce medical resources
(Ashely, 2002; Alora, 2006).

Manson cited the components of medical ethics from the core curriculum for
medical ethics in the British medical schools broad scope and clinical application
of Medical Ethics Education (2008):

Informed consent and refusal of treatment why the concepts of respect for
autonomy adequate information, treatment without consent, competence,
battery, and negligence are important.

The clinical relationship ~truthfulness, trust, and good communication; ethical

limits of paternalism; building trust, honesty, courage, and other virtues in
clinical practice, narrative, and communication skills.

Confidentiality clinical importance of privacy, compulsory and discretionary

disclosure, and public versus private interests.

Medical research ~ethical and legal tensions in doing medical research on

patients, human volunteers, and animals; and the need for effective regulation.

Human reproduction -ethical and legal status of the embryo/fetus, assisted

conception, abortion, and prenatal screening.

The new genetics ~ treating the abnormal versus improving the normal; and
debates about the ethical boundaries of, and the need to regulate, genetic
therapy and research.

Children -ethical and legal significance of age to consent to treatment, dealing

with parental/child/clinician conflict, and child abuse.

Mental disorders and disabilities ethical and legal justification for detention and
treatment without consent; and conflicts of interests between patient, family,
and community.

Life, death, dying, and killing -the duty of care and ethical and legal justification
for the non-provision of life-prolonging treatment and the provision of potentially
life-shortening palliatives, transplantation, death certification, and the coroners
court.
The duties of doctors and medical students public expectations of medicine, the
need for teamwork, the health of doctors and students in relation to professional
performance, professional regulation, clinical mistakes, and whistle-blowing.
Resource allocation rationing and the fair and just distribution of scarce health
care, the relevance of needs, rights, utility, efficiency, desert, and autonomy to
theories of equitable health care, and boundaries of responsibility of individuals
for their own health.

Rights what rights are and their links with moral and professional duties: the
importance of the concept of rights for good medical practice.

BASIC ETHICAL PRINCIPLES AND THE PRACTICE OF MEDICINE

In life, there are eight basic principles that should be followed. These axioms are
congruent to what are taught in medical ethics. They are as follows:

lnvtolabttity of Life

All human life is sacred; as such, family doctors must remember that it is a gift,
the fruit of love. It is a doctor's duty to affirm, respect, love

n d defend it. Doctors must recognize that death

1.: a natural end of life, and that biological life is

not the highest good. One does not have to do everything (disproportionate
means) to prevent death, and at the proper time, a person should be allowed to
die gracefully.

Stewardship

A physician should reasonably, responsibly, and respectfully be a good steward

of all the material things that God gave him/her. Doctors are accountable to the
Creator inasmuch as they are His representatives of His reign on earth.
Therefore, every act that they do must be based on being a good steward. There
is no other profession on earth that has been given this virtue of being a healer,
teacher, manager, social mobilizer and counselor, except that of the physician;
hence, doctors should be good stewards of all the responsibilities attached to
these roles.

Totality and Integrity of the Human Person It should be each and every doctors
commitment to protect the integrity of the body and its functions and to observe
the correlative prohibition of mutilation of the patient's body.

Double Effect "

Every act that doctors do must not be harmful to others; it must be moral and
the basic objective must be for the benefit of the other person that they are
taking care of. There are four conditions that usually apply to the principle of
double effect:

The action itself must not be intrinsically wrong; it must be a good or a neutral
act. Only the good effect, not the bad, must be intended, even though it can be
foreseen. The bad effect must not be the means of the good effect.

The good effect must outweigh the evil effect that is permitted.

The physician may apply these four criteria to the case he/she handles, and
make sure that the principle of double effect applies, and the

four conditions are not violated by the prescribed treatment plan (Manlangit,
2010). Example: Choosing between the life and death of a fetus ' . in a'mother.
who has uterine carcinoma. . '

When considering a medical treatment for a patient, one speaks of ordinary and
proportionate care versus extraordinary and disproportionate care.

Example:

Mechanical ventilation may be ordinary and proportionate for an otherwise

healthy 25oyear-old who suffered a near-drowning accident, whereas a respirator
for an 88 year-old near-terminal patient with cancer of the lung would be
extraordinary and disproportionate.

The reference point is the patient. The continuous exposure to a lot of risks when
dealing with our infectious patients is another example of double effect.

Solidarity

Health care providers must always aim to help patients who are needy and be
able to act kindly and compassionately towards the patients. It is also their duty
to cooperate effectively with the members of a health team. They should be able
to advocate for a just health policy/package accessible to the marginalized,
avoiding profit-making from health services, as well as manipulating or exploiting
the disadvantaged just so they can have personal gain.

Subsidiarity

Physicians must remember that they are entrusted with the functions that they
are capable of performing because of the training that they had. Doctors should
give their patients that human dignity and responsibility to make decisions for
themselves and assist them in that decision they need to take.

Legitimate Cooperation It is a physicians duty to cooperate effectively with the

members of a health team or employees

of a government or private health care institution if it will be for the common

good of the patients, their families, and the community where the physician is
working in (Ashley, 2002; Declaration of Helsinki, 2008). . . . . . . . Human
Sexuality

Issues arise in the new reproductive technology where either the unitized or
procreative functions are suppressed. To exclude one is to offer less than the
whole and to render the union less than complete. An example is the use of
contraceptives and in-vitro fertilization (Ashley, 2002).

BIOETHICAI. PRINCIPLES AND THE PRACTICE OF FAMILY MEDICINE (CURLIN ET AL.

2007)

These are the bioethical principles that govern physicians relationships with
their patients (Malangit, 2010).

Nonmaleticence

In this particular principle, Family Medicine practitioners must always remember

that they should not do, risk, nor create any harm or injury to their patients
either through acts of commission or omission. They must maintain trust and
confidence and the belief that they will not reveal their patients medical records
to others.

Role of Health Care Professionals ' Become the basis for standard of care and
reaffirm the need for competence in everything they do. They must undergo
continuing medical education to upgrade their skills and knowledge so that their
patients will not suffer because of ignorance. Emphasize risks and benefits in
any decision that they must make in managing the health problems of their
patients. 0 Through this principle, the definitions of negligence, malpractice,
physician's error, and medical mistakes are based.

The legal criteria for determining negligence are as follows:

The professional must have a duty to the affected party-just like a patient of a
physician;

The professional must breach that duty; . ' ' , ' . ' The affected party must
experience harm; and .

The harm must be caused by the breach of duty.

This principle affirms the need for medical competence. It is clear that medical
mistakes occur; however, this principle articulates a fundamental commitment
on the part of the health care professionals to protect their patients from harm.

Examples:

Performing surgery on a patient and the physician was not competent to do so.
The patient died in the process. '

Choosing to undergo a painful operation if it will prolong life.

Refusing further procedures like dialysis or CPR if it will only prolong pain and
suffering.

Beneficence

Beneficence refers to the traditional role of the physician as the Good Samaritan.
Compassionate physicians perform acts of charity, kindness, and mercy; come to
the aid of the injured, the sick, and the dying; and relieve suffering. Natural or
comfort care, the offering of food and water, and the maintenance of body
temperature, and cleanliness for the dying elderly patient are forms of
beneficence, as well as comforting the patient through a loving presence,
palliation, and prayer.

Example:

When the patient is incapacitated by the grave nature of accident or illness, it is

presumed that the reasonable person would want the patient to be treated
aggressively, and rush to provide beneficent intervention by stemming the
bleeding, mending the broken, or suturing the wounded.

justice

Justice is both a principle and a virtue tied to physicians interactions and

relationships with their patients and with everyone else. It hinges on fair play,
keeping promises, role commitments, and reciprocity. It is based on the' principle
of giving a person his/her due. The virtue related to it is the constant will to
render what is right. Justice is connected to truthfulness, autonomy, stewardship,
and nonmaleficence. This principle underlies allocation and distribution of
resources and the concept of the right to health care.

Issues on justice occur in public policy, health insurance, health management

organization, research, and relationships with drug representatives. justice is also
equated with equity. What is due to one depends on what he/she has g'ven. It is
also based on the natural law or the golden rule that states "do unto others what
you would want others to do unto you.

There are various of factors used as criteria for distributive justice (See Box 2).

Role of the Health Care Professional 0 In delivering health care, give each patient
what is due: the available care he/she needs, inf rmation, and confidentiality.
rovide equal health care to all patients in: thou! discrimination. W k towards just
health care policies such a delivery of basic health care to all g to their needs. ' A
' g v'ng undue burden to individuals3 poor by using them as learning t r o
inducing them to donate an or ( rice.

Box 2. Criteria for Distributive Justlco

0 each person an equal share Yo each person according to need To each person
according to eitort To each person according to contribution To each person
according to merit To each person according to tree-market e changes
Autonomy

The right of the patient to decide is cauea

autonomy and this should be respected unless his/ her actions constitute an evil
act. ' This principle is the basis'for the-practice of informed consent and
emphasizes the need for the competence and voluntariness to consent or
withdraw the procedures or treatment that a doctor wants to give to the patient.
If the patient is incompetent, a knowledgeable proxy who could give the consent
should be sought. An example is the consent of the parents whose child will
undergo surgery (Tan-Alora, 2006).

Confidentiality

Confidentiality is an important aspect or trusr that patients place in health care

practitioners, especially physicians. Thus, patients have the right to every
consideration of their privacy concerning their medical problem and the
corresponding programs planned to address them. Case discussions,
consultations, examinations, and treatment are confidential and should be
conducted discreetly. Patients admitted to teaching hospitals are made aware of
their rights as patients and the consent they sign upon admission should reflect
the possibility that they will be seen in the presence of students/trainees, or that
they may be attended to by these trainees during emergencies. Permission of
the pat ient's is secured for people who will be present during discussion. Sharing
patients' information in the Web for the purpose of teaching/consultation is now
an issue of confidentiality. Physicians should always be conscious of
confidentiality and help protect/ assure patients' privacy (Edge & Groves, 1999).

Role Fidelity

Modern health care is the practice of a team. Even family registration with
primary care benefits is done with primary care facilities. No single individual can
maintain the databank of information needed to provide care. Nurses and
physicians' assistants have patients' data and observations written in the
patients' charts

which physicians should take time to read. Listed with the Professional
Regulation Commission are all health professionals who take licensure
examinations. Each field of the health profession has defined competencies,
Family Medicine specialists huVe their own competencies of things to know and
things to do which should be clear with other specialists and patients. Whatever
the assigned role, the ethics of health care requires that practitioners practice
faithfully within the constraint of their role (Edge 8: Groves, 1999).

Veracity

Veracity binds both the patients and health practitioners in an association of

truth. Patients must tell the truth concerning their history and their feelings and
concerns about their problem/s to their health practitioners, most especially
their physicians. These disclosed facts shall enable the practitioners to provide
appropriate care. The physicians need to disclose factual information, so their
patients can exercise personal autonomy (Edge 8: Groves, 1999).

The family doctors should fully inform their patients and defer to the latters
option in accepting or rejecting the proposed plans of management. They must
be able to give the . diagnosis, the therapeutic management-which must be safe,
effective, With minimal ill-effects, available, and are acceptable (culturally,
religiously, or ethically)--the prognosis, and the financial implications of the
chosen management procedure. In any case of conflict between religion, culture,
and legalities, the dignity of life should prevail. The promotion and advancement
of the health of the patients should be prioritized over the perks of the
physicians and of the health product industries. Physicians should hold as sacred
and highly confidential whatever may be discovered or learned that is pertinent
to the patients even after the patients death. except when the promotion of
justice, safety, and public health requires them to act otherwise. thsicians should
be free to choose patients.