MYANMAR ACADEMY OF MEDICAL SCIENCE

The First Myanmar Academy of Medical Science Oration 12 August 2001

HUMANISM AND ETHICS IN MEDICAL PRACTICE, HEALTH SERVICES, MEDICAL

EDUCATION AND MEDICAL RESEARCH

Professor U Mya Tu, M.B.,B.S. (Rgn), Ph.D. (Edin)

Formerly Professor of Physiology, Faculty of Medicine, University of Rangoon, Retired Director-General, Department of Medical Research, Yangon, and

Retired Director, Health Systems Infrastructure, World Health Organization, South-East Asia Regional Office, New Delhi, India

Myanmar Academy of Medical Science 27, Pyidaungsu Yeik Tha Road,

Dagon Township, Yangon, Myanmar

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The First M.A.M.S Oration

The Myanmar Academy of Medical Science was founded with the objectives,

inter alia, to contribute knowledge and expertise of medical scientists in building a

peaceful modern developed nation, and to undertake the progressive improvement of

health care of the people. The duties of the Academy of Medical Science include

holding meetings for paper presentations and lecturing and demonstrating in

dissemination of medical education (Medical Science).

The Academy therefore had undertaken various scientific works and activities

to attain these objectives. During the past two years, the Academy has organized four

Symposia on various subjects, a workshop on developing research culture, scientific

meetings, and supported a number of Quick and Simple Research projects and

commissioned writing books.

The first MAMS Oration is being organized as a major scientific activity

aiming at promoting interest and disseminate knowledge. Webster's Encyclopedic

Unabridged Dictionary of the English Language defines Oration as a formal speech,

especially one delivered on a special occasion. According to the Shorter Oxford

English Dictionary, an Oration is a formal speech, or discourse, especially one

delivered in connexion with some particular occasion. Oration is a structured speech

delivered on a formal occasion presented by an orator, who, by invitation is a

distinguished personality.

The title of this present oration is " Humanism, and Ethics in Medical Practice,

Health Services, Medical Education and Medical Research". The subject is a very

topical one. Humanism and Medical Ethics are fundamental and at the core of all

endeavours of the medical profession, be it medical practice, medical education,

health care services or medical research. All members of the medical profession are or

should be governed by these principles.

The orator for the First MAMS Oration is Professor U Mya Tu, a medical

graduate from Yangon and the first Myanmar to obtain Ph.D in Physiology, the

founder Director General of Medical Research Institute and finally retired from WHO

service as Director of Health System Infrastructure in SEARO New Delhi.

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Biography of Professor U Mya Tu

Professor U Mya Tu was born in Yangon on July 20. 1927. He attended St.

Philips English Middle School and St. Paul's Institute, East Yangon before World War II

broke out in the east. He passed the High School Final Examination in 1943 from the

Government High School at Maubin. During the war, he attended the Licentiate of the

State Medical Board (L.S.M.B) medical course, which was the only medical course open

at that time. After the war, passed the Matriculation Examination of the University of

Rangoon and in 1946, he was admitted to the First M.B.,B.S class at the re-opened

Rangoon Medical College.

During his undergraduate career, he took an active part in student social affairs,

being Secretary of the Medical College Student's Union, member and later Chairman of

the Social Committee of the Medical College Student's Union, and Editor of the Medical

College Students Union Magazine. He graduated M.B.,B.S. in 1951 and was posted to

the Yangon General Hospital as a Civil Assistant Surgeon. After about a year, he was

transferred to the University of Rangoon service as Assistant Lecturer in Physiology at

the faculty of Medicine, Rangoon. He then went on a State Scholarship to the University

of Edinburgh and studied physiology under Professor David Whitteridge, F.R.S. He was

awarded the Ph.D. degree in 1956, for his doctoral thesis on the electrophysiological

properties of cardiac muscle and Purkinje tissue. One of his examiners was Sir Andrew

Huxley, the 1959 Nobel laureate in Physiology and Medicine. Professor U Mya Tu was

the first Myanmar national to obtain the Ph.D degree in Physiology.

On his return to Myanmar, Professor U Mya Tu was promoted Lecturer in 1957,

and in 1959 was appointed Professor of Physiology at the Faculty of Medicine,

University of Rangoon, thus becoming the first Myanmar full-time Professor of

Physiology at the University of Rangoon.

Professor U Mya Tu was instrumental in forming the Burma Medical Research

Society in 1957 and was its first Secretary. In April 1962, Professor U Mya Tu led a

Burma Medical Research Society scientific expedition to the Arumdum valley in the

extreme north of Myanmar to study the pygmy Taron tribe. Other members of the

Expedition Team included Professor U Ko Ko, the present President of the Myanmar

Academy of Medical Science and Professor U Aung Than Batu.

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In June 1962, the Minister of Health and Education Colonel Hla Han gave the

responsibility of opening a new Medical College in Mingaladon to Professor U Mya Tu

and Major Ko Ko Gyi the Officer on Special Duty at the Ministry of Health and

Education. Detailed plans were drawn up, buildings renovated and converted to the

laboratories, and equipment procured, and the new Medical College was duly opened

with Major Ko Ko Gyi as the Dean. Professor U May Tu was appointed Part-time

Professor of Physiology at the new Medical College on July 1, 1963, in addition to his

duties as full-time Professor of Physiology at the Landamadaw Medical College.

At the same time as preparing to open the Medical College at Mingaladon,

Professor U Mya Tu was entrusted by the Minister of Health and Education Colonel Hla

Han in August 1962 with the responsibility of drafting an Act for establishing a Medical

Research Council in the Country. The Burma Medical Research Council Act was passed

on October 6, 1962 by the Revolutionary Council Government. Professor U Mya Tu was

appointed Member-Secretary of the Burma Medical Research Council with the

immediate task of opening the Burma Medical Research Institute in the premises of the

Harcourt Butler Institute for Public Health on Zafar Shah (now Ziwaka) Road, Yangon.

The Burma Medical Research Institute came into being when the Harcourt Butler

Institute buildings were officially handed over by the Director of the Harcourt Butler

Institute to Professor U Mya Tu on June 10, 1963. Professor U Mya Tu was appointed

part-time Director of the Burma Medical Research Institute. He became the full-time

Director in 1964. In 1972, the Burma Medical Research Institute was renamed the

Department of Medical Research and Professor U Mya Tu became the Director General.

He served as the chief executive of the Department of Medical Research for a period of

over 13 years.

He was also one time Editor of the Burma Medical Journal and Chairman of the

Board of Editors for the Union of Burma Journal of Life Sciences, and was on the

Editorial Board of several international medical journals. He was Chairman of the Burma

Committee for the Olympic Medical Archives of the International Federation of Sports

Medicine, Switzerland, a Correspondent for the Human Adaptability Section of the

International Biological Programme, U.K., a Member of the International Committee for

the Standardization of Physical Fitness Tests, Japan, and a Member of the Committee on

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Diabetes, Obesity and Cardiovascular Diseases, International Union of Nutritional

Sciences.

In 1977, Professor U Mya Tu joined the WHO, South East Asia Regional Office

as Regional Adviser in Health Manpower Development on deputation from the

Government. He was then appointed successively as Chief of Health Manpower

Development and as Director of Health System Infrastructure till his retirement from

WHO in 1987. His contributions during his ten years with WHO include, promoting the

reorientation of medical education in the countries of the WHO South-East Asia Region,

initiating and promoting the development of the Health Literature and library Services

(HELLIS) Network in the SEA Region, and the conceptualisation of the comprehensive

health system based on primary health care, and the development of the Primary Health

Care Model.

Professor U Mya Tu's research interests and publications have been wide in the

fields of electrophysiology of the heart, physical fitness and sports physiology,

population genetics, medical education, primary health care and the HELLIS Library

Network. He is also the author of a number of books, which include the WHO 40th

Anniversary Volume entitled "Health Development in South-East Asia", in 1988, and its

Update in 1992, and also the 50th Anniversary Souvenir volume for the World Health

Organization, Regional Office for South-East Asia entitled "Fifty Years of WHO in

South –East Asia-Highlights: 1948-1998"

Professor U Mya Tu has been the recipient of several international honours and

academic awards during his career.

Professor U Mya Tu's hobbies include music. He plays the piano for relaxation.

He is also a keen golfer and he led the Department of Medical Research Team to victory

for three successive years in 1973, 1974 and 1975 in the Inter-Professional/ Trade Golf

Tournament at the Burma Golf Club.

Since his retirement in 1987, Professor U Mya Tu has served as a consultant to

the WHO both at Headquarters in Geneva, and at the Regional Officer for South –East

Asia in New Delhi. He is at present working on the "Who's Who in Health in Medicine in

Myanmar" Project together with his wife Dr. Khin Thet Hta.

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HUMANISM AND ETHICS IN MEDICAL PRACTICE, HEALTH SERVICES,

MEDICAL EDUCATION AND MEDICAL RESEARCH

(The First Myanmar Academy of Medical Science Oration)

By

Professor Mya Tu∗∗∗∗

Mr. Chairman, the Honourable Deputy Minister of Health, Professor Mya Oo, His Excellency the Honourable Minister of Health, Major-General Ket Sein, The Honourable President of the Myanmar Academy of Medical Science, Professor U Ko Ko, Distinguished Members of the Myanmar Academy of Medical Science, Honoured Ladies and Gentlemen, It is indeed a great honour and privilege to be asked to deliver the first oration of the Myanmar Academy of Medical Science before this august assembly of Academicians. I have chosen as the subject of my Oration “Humanism and Ethics in Medical Practice, Health Services, Medical Education and Medical Research” because in this present age and climate of materialism, reductionism and economic rationalism, the medical profession is in danger of losing sight of its social roots and its high ideals of altruism and service to humanity. First, I would like to define what I mean by the terms “Humanism’ and "Ethics". The meaning of ethics is well understood. Stedman's Medical Dictionary defines medical ethics as the principles of correct professional conduct with regard to the rights of the physician himself, his patients, and his fellow practitioners.

The term "humanism" needs a bit more explanation. Originally the term referred to a philosophical and cultural movement during the 15th century European Renaissance. But later it came to mean an attitude that was concerned with human interests and stressing compassion and individual dignity. It is in this latter sense that I use the word ‘humanism’ in my Oration. What does humanism in medicine imply? It implies respect for the dignity of the patient as an individual human being; it implies showing feeling of compassion and an ∗ Formerly Professor of Physiology, Institute of Medicine 1, Yangon , Director-General, Department of Medical Research, Ministry of Health, Yangon, and Director, Health Systems Infrastructure, World Health Organization, South-East Asia Regional Office, New Delhi, India

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understanding of his/her fears and apprehensions; and it implies meaningful communications with the patient to understand him/her as a whole person and not just as a disease. Humanism in medicine is more than medical ethics. It is more than refraining from doing physical and mental harm to the patient through professional misconduct. It is more than just abiding by the Hippocratic Oath. Humanism is a positive action, just as compassion is not only a feeling of concern for the suffering of others, but also prompting action to give help or to promote its alleviation. It is indeed surprising that a definition of 'compassion' is not included in two major Medical Dictionaries – Dorland's and Stedman's. Yet compassion is as important as scientific knowledge and skills in a humanistic physician.

What is the present situation with regard to the degree of humanism and ethics imbued in the medical profession today at the beginning of this 21st century?

In the 1999 Year Book commemorating the Silver Jubilee Reunion of the Class of

1974-75 Medical Graduates of the Institute of Medicine 1, Yangon, there were a number of Commemorative Messages from retired teachers. Two struck me as resonating with the theme of this Oration. One was by Professor Dr. Daw Khin Si, who wrote: "Human Relationship is important....Patient understanding is the secret of all human relationship....".

Dr. Maung Maung Taik was more explicit. This is what he wrote:

"... I must however add, with malice towards none that the present ethical standard of our noble profession is much to be desired. We, as doctors, should safeguard ourselves from human frailty: the lure of lucre. There is much need to uphold the ideals of our noble profession today and to avoid practices that tarnish its name. We need to abide by the sacred tenets enshrined in the Oath. Let us go out of our way to be more compassionate to the suffering of the poor and the needy. Let us be doctors of mercy and charity: rather than the doctors of money and affluence...."

What is it that has made these two respected teachers to voice their apprehensions

of the state of our profession? When we take stock, we will realize how far we have strayed from the ideal. This

phenomenon is a world wide one and unfortunately it has also spread to our country. Not only has medical practice and the care of patients deviated from the original social ideal, the concept of humanism is almost alien in medical education and medical research endeavours. True, medical ethics is part of the curriculum in a number of medical schools, but it has been alleged that medical faculties insert the teaching of medical ethics in the curriculum to salve their consciences. As will be described a little later, much more than inclusion of the subject of medical ethics in the curriculum is required for medical graduates to imbibe humanism and ethical behaviour as their second nature.

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Humanism and ethics in medical practice Caring for the sick at its most fundamental level is rooted in the human spirit and humanism. Take for example the young mother caring for her young sick infant or child; or her kith and kin rallying round her offering advice, helping wherever needed; or an older woman friend in the community who have experience in looking after the sick responding to the call of the young mother for help. All of them have no pecuniary motive save compassion for the sick child.

At a different level are the priests, priest-doctors, and witch doctors who since time immemorial have taken to treating sick people because of the belief of ancient people that disease is a manifestation of evil influence exercised by a god or supernatural being or another human being. Their motive for curing sick people may not wholly be altruistic for certainly they benefited from the offertories, in addition to the power and authority it gave them over the community.

When it comes to the medical profession, we are made to believe that its social

origins are rooted in its attitude of humanism, a compassion for our suffering fellow people, and a desire of being of service to them. Present day medical practitioners and specialists have a one-to-one doctor-patient relationship. It is a unique relationship, and a very private one, involving a complete submission, dependence, and trust of the patient to the authority, knowledge and skills of the doctor. And with that authority comes the social obligation to treat with compassion those who trust us and are dependent upon us.

In spite of this relationship and the authority the doctor has over the patient, the prestige and status of the medical profession in society was not always as high as we have seen it in the 20th century. For example, in ancient India, the status of physicians, was not high, except for the King's physician who was highly honoured especially during times of war and had his tent next to the King's with a flag of his own. According to Manu, the first law-giver in India, the physician was considered to be always impure and was never invited to sacrifices offered to the gods. A Brahman was not supposed to eat the food given by a physician because it was considered vile (Rao & Radhalaxmi, 1960). In the Roman Empire, physicians were slaves, freedmen and foreigners, and medicine was considered a lowly occupation. In 18th century England, surgeons and apothecaries were considered as tradesmen, and physicians were at the margins of the gentry class. Even as late as the 19th century, doctors in France were extremely poor and lacked status (Starr, 1949).

However, with the growth and advances in medical science and the ability of doctors to radically influence the course of disease, beginning in the latter part of the 19th century, medicine gradually changed from a trade to a profession and the power and prestige of the medical profession have correspondingly increased reaching an all time high in the 20th century.

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When medicine gained the status of a profession from that of being a trade, it acquired all the characteristics of a profession, namely autonomy, controlling the entry into the profession, maintaining the standards of competency through training which included theory, as compared to just skills training for tradesmen. The medical profession thus organized the structural institutions of professions, such as associations, publications and medical schools that they controlled, and had as its aim the altruistic or humanistic service to society. It also constituted bodies to develop and apply a code of professional conduct and ethics. Ethics has been a fundamental part of medicine since early times and dealt with the obligations and responsibilities of the physician. The principal concern of the doctor for the welfare of his patient and the clear admonition to do no harm were embodied in the Hippocratic Oath. It should be noted however that all the statements of ethics were professionally oriented. There were none concerning the humanistic aspects.

Practitioners of medicine have been governed by codes of conduct since recorded history. The earliest known code is that of Hammurabi, the Babylonian King who lived about 2000 B.C. It prescribed rewards for successful treatment and punishments for failure. In the code of medical ethics of ancient Egypt also, punishments were meted out for malpractice that were even more severe than those of the Babylonian Code of Hammurabi, even to the extent of forfeiting the physician's own life. These codes were imposed on the medical practitioners by kings and rulers. Hence their harsh nature. The next well-known Code is that of the physician Hippocrates (460 – 355 B.C.) , exemplified in the Oath which is familiar to all medical graduates. In this code of ethics, the graduate is reminded of the dignity and responsibility of his calling, and among other things, urged to seek above all the benefit of the patient, and taking no mean advantage of the position of the medical adviser. In his Aphorisms he mentions the idea of focusing full attention on the patient, rather than on theories of the disease. No more are the extreme penalties for failing to cure. (Sigerist, 1961) The pattern of medical practice in the early eighteenth century was the “Solo Fee-for-Service” type of practice where the individual doctor renders medical services for a fee, the fees being either money or some farm produce as still occurs in developing countries in some very poor communities and villages. This was the age of the country or 'horse and buggy' doctor or the family doctor who knew the families in the villages or community well, went on house rounds, and often acted as 'guide philosopher and trusted friend', in addition to treating all the illnesses in the family. The development of major cities and hospitals during the 18th and 19th centuries saw the country doctor slowly disappear as more and more doctors settled in the urban areas to practice medicine. Some authors have commented that the disappearance of the country 'horse and buggy' or family doctor has contributed to the beginning of what has been called 'dehumanized care' in the hospitals.

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Within the last few decades of the 20th century, the pattern of medical practice radically changed in industrialized countries with market-oriented economies. From the solo individual practice type of organization, there are now more of group practices, where the medical services are provided by a group of three or more doctors under a formal agreement for the joint use of facilities and equipment and allied health personnel, the incomes being distributed according to a previously agreed upon plan. During the 1970s and the early 1980s, business in the developed countries particularly in the United States, saw a big market in the health care field, resulting in an increasing commercialization of medical care, and the growth of the medical industrial complex. Large for-profit corporations were formed offering to government and business purchasers on a pre-payment basis a variety of packages of services, including a range of products from “wellness” programmes through organ transplantation to hospice services. With doctors forming into groupings, and the practice of medicine becoming big business with health care corporations reaping revenues in billions of dollars, medicine is no longer a cottage industry as the traditional fee-for service solo practice was termed. This meant that it is the managers of these corporations – the economists and the Chief Executive Officers, rather than doctors who are deciding more and more on the type of health care practice and organization. With emphasis on cost-containment and efficiency, these managers of the for-profit corporations are placing restrictions and applying pressure on the physicians or their staff to follow prescribed patient care protocols, reduce admissions and patient length of stay in the hospital, and the number of diagnostic tests, resulting in an overall loss of control over aspects of patient management by the doctor. The reverse situation applies when the doctor has financial interests in the company operating a private hospital and is encouraged to employ high-tech diagnostic tests and procedures. In both cases, it is the patients who come worse off. The result of this commercialization of medicine has been a sky-rocketing of the cost of drugs and medical care consequent upon the application of highly sophisticated medical equipment in diagnosis and treatment. While the rational and systematic use of high technology procedures is definitely of benefit to the patients, indiscriminate use with a profit motive is to be deplored. It has been said that the more physicians come to depend solely on technology, the more they lose their humanism, continuing the slide towards 'dehumanized care'. This is compounded by the fear of being sued for malpractice, doctors paying a high insurance premium, which is of course passed on to the patients, driving the cost of medical care still higher.

This situation in developed industrialized countries with market-oriented economies is also being reflected in the developing countries. Fortunately litigation for malpractice has not yet reached our shores.

These changes have coloured the behaviour and attitudes of the profession, with increasing emphasis on the financial and technological aspects of treatment to the detriment of the altruistic and humanitarian calling of the profession.

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In this context, the following words of that great humanitarian and physician of the late 19th and early 20th centuries, Sir William Osler, came to mind: "If I can ease one life its suffering and brush away one pain. If I can stop one heart from breaking --- I will not have lived in vain. "If I can help one ailing brother regain his strength again. If I can calm one weeping mother ---

I will not have lived in vain". "If I can ease one life its suffering and brush away one pain". He did not say "I will wait for the admission forms to be filled and all the bureaucratic procedures to be completed, and then I will try to ease the suffering and the pain of the patient". "If I can stop one heart from breaking –" He realised the anguish and suffering that illness can cause, not only to the patient, but also to the family members. "If I can help one ailing brother regain his strength again". He talks of a 'brother', not a patient or a case. "If I can calm one weeping mother – " He did not say he would stop a mother from weeping by curing or healing all illnesses. A physician's role does not end when the patient dies, but to provide a calming, reassuring, soothing influence even in tragedy.

In the March 2000 issue of the Myanmar Medical Journal the editorial dwelt on the same subject of medical ethics. You might remember that the title of the editorial was "Of Patch Adams and Goose Eggs". (Nyunt Wai, 2000) The thrust of the editorial was on financial aspects, on altruism, the observance of professional ethics, and on practicing what 'Patch' Adams called "a little bit of excessive happiness ". Dr. Hunter D. "Patch" Adams to give his full name, is an American doctor, a social revolutionary who believes that care of the sick should not be a business transaction; that the doctor-patient relationship has deteriorated from the time when doctors gave time to listen and communicate with patients, to the aloofness of doctors nowadays, because of undue dependence on technology. A video version of the film on Patch Adams is available and is worth watching for a number of telling commentaries Patch Adams makes. For instance, he criticizes the Medical Superintendent telling him: "You don't even look at people when you're talking to them.... You don't connect to people". And again when he argues his defence before the Medical Board: "Death is not the enemy, gentlemen. It is indifference. You treat a disease, you win or lose. You treat a patient, you will win, whatever the outcome".

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Some of you who have seen the satirical popular British TV series "Yes Minister", might remember that in one episode, it is the bureaucracy that is against the patient. When the Minister asked why the new hospital was still not admitting patients but had employed the full complement of non-medical administrative and other staff, the Health Secretary replied: "They have great experience at the Department of Health and Social Services in getting hospitals going. The first step is to sort out the smooth running of the place. Having patients would be of no help at all – they'd just get in the way". Even during the medieval period, physicians and surgeons recognized the importance of treating the patient in addition to the disease. It has been reported that one Henri de Mandeville (1260-1320) suggested a method 'to solace (the patient) by playing on a ten-stringed psaltery". He even suggested some dubious means such as writing false letters telling him of the death of his enemies, or if he is a canon of the church he should be told that the bishop is dead and that he is elected. I am not suggesting that present day doctors should follow explicitly the advice of Henri de Mandeville and start to learn how to play a musical instrument to entertain patients or to employ such unethical methods as he advocated. However it goes to show that even in those days, doctors tried what they called "sustaining the spirits of the patient" in addition to treating the disease. In passing, it should be noted that it is not only the practicing clinicians who forgot the humanitarian roots of their profession in their drive for technological excellence. In the field of public health also, where the dictum is "the greatest good for the greatest number", there are instances where the individual patients suffered. Consider the treatment of lepers in ancient and until relatively recent times when they were treated as social outcasts. Some years back I occasion to visit the Molokoi Island, once a leper colony in the Hawaii Islands and associated with the name of Father Damein. I was told of how lepers were rounded up in the main Hawaii Islands and taken by ship to Molokoi Island where they were told to jump from the ship and swim ashore, or those who were hesitant, were pushed into the bay. Consider also the imposition of quarantine for plague and cholera in the early days. Where was humanism then? Humanism and ethics in the health services

Since ancient times, kings and rulers have taken the responsibility of looking after the health of its people. There are records that in ancient India, the Kings established places where the sick and disabled were cared for. The ancient Ayurvedic literature mentions specifications of different types of hospitals like obstetrics and surgical hospitals. Asoka's Rock Edict II (4th century B.C.) described curative arrangements and hospitals or dispensaries for men and animals. (Rao & Radhalaxmi, 1960) In the Roman Empire, medical services for the poor and for their legions were organized. Public physicians were appointed to attend the poor and to supervise medical practice within their area. The first hospital in Rome was built on the island of St. Bartholomew in 293 B.C. Later various writers mentioned the existence of private hospitals and nursing homes (Guthrie, 1958).

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During the Dark Ages in Europe, when intellectualism and experimentation were discouraged, it was in the monasteries that the light of medicine was maintained. Many monasteries had herbal gardens and hospices. During this period, medicine in the Arab countries flourished. There were magnificent hospitals in Damascus, Cordova and Cairo, which catered to all aspects of patient care, including the humanistic aspects: such as the spiritual side (where speakers recited the Koran day and night without ceasing); the aesthetic aspects (such as playing soft music at night to lull the sleepless); and aspects for lifting the spirits (such as having storytellers to amuse the patients). The rehabilitative aspects were not overlooked. Each patient, on departure was given a sum of money, sufficient to tide him over convalescence, until he should be fit to resume work (Guthrie, 1958). It was a very humanitarian approach to patient care indeed! In Europe, particularly England, heath services for the population as we know it and sponsored by the State, is a relatively late phenomenon, although from medieval times the State has taken emergency measures and ad hoc legislation to deal with epidemic diseases. In the early 19th century, as a result of the industrial revolution, there were growing health and social problems while there was no legislation to deal with these problems and no central or local authority specifically concerned with the health of the population. It took a cholera epidemic in 1831 for England to form an emergency Board of Health which later became the General Board of Health. A Ministry of Health was not formed till 1919. Nowadays all countries regard the preservation of the nation's health as one of their moral duties and have formed Ministries of Health or similar Agencies. Hospitals have sprung up but mainly concentrated in large cities and urban areas.

During the first part of the 20th century, the health care system in industrial countries developed around hospitals. After World War II, developing countries on gaining independence followed the health care delivery system of the industrialized countries, and built huge hospitals or as Dr. Halfdan Mahler the former Director General of WHO called them, "disease palaces". By the late 1950s and 1960s societal pressure on the medical profession for change in the manner of medical and health care became more pronounced. The spectacular advances in medical care using highly sophisticated technology was acknowledged. But it was costly and was available only to those few who had access to and could afford it. The plight of the vast multitude of the poor as well as the rural population went unserved or underserved. Doctors whose training was hospital-based, using sophisticated technology, and instructed by academic research-oriented professors were ill-equipped to deal with the health problems in the community and with the new developments in health care. These trends were disturbing to society. At this time, a new philosophy of health development based on equity and social justice was evolving in WHO which ultimately resulted in the Primary Health Care and the Health for All movements. (World Health Organisation, 1981)

The voices of two eminent people eloquently expressed the situation of the health

care system in the 1980s. The situation is not much better today. Jimmy Carter, the ex-President of the United States, said: "...Although American medical skills is among the best in the world, we have an abominable system in this country for the delivery of health

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care with gross inequities towards the poor – particularly the working poor – and profiteering by many hospitals and some medical doctors who prey on the vulnerability of the ill" Dr. Halfdan Mahler, the ex-Director-General of WHO describes the global view: " ...The general picture in the world today is of an incredibly expensive health industry catering not to the promotion of health, but to the unlimited application of disease technology. This perversion of health work is self-perpetuating. There is a vast professional establishment concentrating on the problems of the few. The whole "unhealth" system finds its most grandiose expression in buildings, in "disease palaces' with their ever growing staff needs and sophistication." As stated previously, in relatively recent times under market economy, medicine has become big business even in developing countries. Large corporations have moved into what has been called the medical industrial complex. And when medicine is run as a business for profit, there is a rise in the cost of medical care, thereby further denying medical care to the poor. The relationship and attention given to the poor patients also do not match that given to the more well-to-do. It is true that the State subsidized hospitals are there to cater to the needs of poor patients, but the reality is there are costs involved in attending any hospital and it has been known that many poor patients have foregone treatment in hospital rather than have the family face financial ruin. Humanism and ethics in medical education

What is it then that makes a doctor technically proficient and also develop an

humanistic attitude, to cultivate 'bedside manners'? Is it part of the training and education of medical students and the role model of the Professors and other teachers? So let us now turn our attention to humanism and ethics in medical education. Both in the western world and in the eastern traditional cultures, the training of future medical practitioners originated with the apprenticeship system. In the west, up until the eighteenth century, the majority of practitioners received their training through this system. This was a highly decentralized system of training in which the apprentice and the master were bound in a personal relationship. In India, this traditional method of teaching through a close personal relationship between the pupil and the teacher of Ayurvedic medicine dates back to a few thousand years B.C. The pupil stayed in the house of the teacher and in fact became a member of the household also doing household chores, the teacher being actually regarded as a father. (Bhatia 1977) In ancient Greece, the apprentice paid the master a fee, and spends a number of years with him, assisting him, and learning and observing, until the day came when he was a master himself. (Sigerist 1941). Though an uneconomical method of production of physicians, nevertheless, there is much to be said for this traditional apprenticeship system. With such a close association and relationship with the teacher for several years, the student not only learns from the teacher, but also imbibes his philosophy, his moral behaviour, his attitudes, values and methods from his daily life and his work and the way he deals with his patients – in fact his 'bedside manner'. This is very similar to the present day one-to-one

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relationship between a Ph.D. student and his Professor supervisor, where the student working on a research problem together with his/her supervisor, imbibes the Professor's approach, his methods, his way of thinking and the way he attempts to solve problems. The next change in the system of training physicians occurred under the Roman Empire. Because of the great need for physicians and surgeons for their armies, the State took responsibility for the training of physicians and surgeons by appointing teachers. (Sigerist 1941).During the ensuring centuries, a number of countries followed suit. In the Islamic countries, the education of physicians was already well established by the eighth century A.D. The Islamic rulers founded hospitals with schools for teaching medicine attached to them. Well-to-do citizens also set up private hospitals employing reputed physicians who had the dual responsibility of treating patients in the hospital as well as to teach the medical students. The famous medical schools in Europe in the ninth to the thirteenth century A.D. - Salerno, Montpellier, Bologna and Padua - put medical education on a sound basis and medical degrees were granted after a definite course of study and examinations. The faculty of the medical schools during this period not only trained physicians but also controlled their actions, thus gradually assuming the same functions as the craftsmens’ guilds of the period. During the Renaissance, medical faculties gradually lost their power to control the practice, which in many countries were taken over by the State, and State Medical Boards were formed. (Sigerist 1941).In England, the General Council of Medical Education and Registration – more commonly known as the General Medical Council, was established by the Medical Act of 1858 specifically to regulate the profession on behalf of the State, to oversee medical education, to control the professional conduct and ethical behaviour of the profession, and to maintain a register of qualified practitioners. Since the Council membership was primarily of doctors, this in effect gave the profession the task of regulating itself. In Europe, with the development of more hospitals in the nineteenth century, the traditional apprenticeship system gradually gave way to a more centralized system of medical education, firstly in the hospital medical schools and later in the universities. As more and more students were being trained in hospitals, the plight of the hospital patients seems to have been overlooked. Clinical teaching of a large number of students had its effect on patients. As early as Roman times, under the apprentice system, one Latin poet by the name of Martial, who lived in the 1st century AD complained: "I'm ill. I send for Symmachus; he's here, A hundred students following in the rear; All paw my chest, with hands as cold as snow:

I had no fever; I have it now." Sounds very much like a contemporary scene in a teaching hospital!

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The nineteenth century saw dramatic scientific advances which was to have profound effect both on medical practice and on medical education. Medical practice in the early nineteenth century had been more or less of an empirical nature. But with medical advances and discoveries, vaccination against smallpox, the establishment of the bacterial origin of many diseases, and the introduction of anti-rabies vaccine and of diphtheria antitoxin, and with some preparations such as digitalis, cinchona bark, morphine and aspirin, physicians now had some effective preparations at their disposal. They could therefore afford to give up the time-honoured heroic but ineffectual measures such as blood-letting, purging and blistering. All these developments strengthened the armamentarium of the medical profession and contrasted sharply with the “therapeutic impotence” of the practitioners prevailing during the early part of the nineteenth century. The result was an increased faith of the public in the application of science for the alleviation of human suffering, at the same time enhancing the prestige and status of the profession. The effect of these developments on medical education was also far-reaching. The teaching of the basic sciences that had hitherto been neglected or haphazard was now regarded as the foundation of medicine. The training of medical students became more systematized during the twentieth century particularly after the 1910 Flexner Report which analysed the state of medical schools in the USA and gave recommendations to place them on a sound scientific footing. The teaching of the basic preclinical sciences accompanied by dissection and experiments in the laboratory in the first few years of the medical course became the standard model. The Flexner Report had far reaching effects beyond the borders of the USA. And to this day the basic structure of the organization of medical education in many countries is largely based on the three segments of premedical, preclinical and clinical areas. With this increased emphasis on basic science teaching, medical education became closely wedded to academic medicine and research.(Starr 1949). Nowhere was this more so than in the United States, and even the newly independent ex-colonial countries after World War II tried to emulate this model of medical education. This emphasis on academic and technological medicine taught in large university hospitals extended right into the twentieth century. As a consequence, students graduating from these medical schools, being trained in a university hospital setting with excellent facilities were reluctant to work in less well-endowed hospitals or to go to the small towns and rural areas. In any case, their training was such that they were ill-prepared to work in a community setting. The result was that these areas remained unserved or underserved. Reform in medical education This state of affairs in medical education existed till the 1950s. The emergence of the concept of Social Medicine and the introduction of the teaching of social and preventive medicine in the curricula in place of Public Health, gave the required impetus for medical schools to bring about certain changes in the hope of preparing doctors to be able to deal with this problem of the large underserved and underprivileged population in the nation (Ko Ko, 1987). A little later the concept of Community Medicine was introduced in the medical schools and was particularly promoted by the World Health

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Organization in the 1960s and the 1970s. By that time the need for reform in medical education had become apparent. Many medical schools made serious efforts at reform, concentrating:

Firstly on where medicine should be learned (in the community, including home

visits and clinical teaching in hospitals, as against solely and exclusively in the University teaching hospital setting).

Secondly on how medicine should be learned by (changing the curriculum or what has been called 'curriculum shuffling', for example, introduction of behavioural sciences, and medical ethics, and a change in emphasis from public health to preventive and social medicine, and latterly to community health, and by changing the methodology of teaching such as small group learning and Problem Based Learning). All sorts of integrated teaching were experimented with – the horizontal, and the vertical, and also as one wag put it spiral integration when everyone got screwed up! and finally gave up. It should be mentioned that integrated teaching requires leadership, and a lot of coordination and cooperation. It also requires a constant input of energy to keep the system running.

Thirdly, medical education reform has tried to concentrate with what should be learned during medical school and this has been more intractable. With such a rapid rate of increase in knowledge and new disciplines, medical educators face a daunting task in determining what to leave out and what new things to include. All Professors jealously guard their subjects resisting any attempt at reducing their curriculum time. Of course, it is some other Professor's subject that should be reduced. And most often than not, the opinion of the politically powerful Professors prevail! Here also there is excellent opportunity for good group dynamics and for cooperation and coordination to arrive at the most suitable curriculum mix relevant and appropriate to the local situation.

Recently WHO has introduced the concept of social accountability of medical

schools, advocating that medical schools review their activities in the three main domains of Institute responsibility, namely Education, Service, and Research in relation to the fundamental values of social accountability of relevance to priority health problems in the country, quality, and cost-effectiveness of health care provided, and equity in the provision of health care services, i.e. provision of care for the underserved and the underprivileged (Fig. 1)

al Accountability Grid for Medical Schools

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Fig. 1 SOCIAL ACCOUNTABILITY GRID FOR MEDICAL SCHOOLSFig. 1 SOCIAL ACCOUNTABILITY GRID FOR MEDICAL SCHOOLSFig. 1 SOCIAL ACCOUNTABILITY GRID FOR MEDICAL SCHOOLSFig. 1 SOCIAL ACCOUNTABILITY GRID FOR MEDICAL SCHOOLS

Medical educators agree that the purpose of these reforms is to redirect medical education towards a community-based experiential, learner-centred model that will enable doctors to be both life-long learners and practitioners with the knowledge and skills available to equate the psychosocial and biological aspects of medical care (Bloom, 1989). In the WHO South-East Asia Region, medical educators meeting in 1987 agreed that the goal for the Reorientation of Medical Education (ROME) was that "... all medical schools in the region will be producing, according to the needs and resources of the country, graduate or specialist doctors, who are responsive to the social and societal needs, and who possess the appropriate ethical, social, technical, scientific, and management abilities so as to enable them to work effectively in the comprehensive health system based on primary health care ...". (World Health Organisation, 1988) It should be noted that both the objectives include ethical, social or psychosocial aspects of medical care.

The training of medical students is one of the areas in which ethical and humanistic considerations can be focused, because this is where the attitudes and perceptions of tomorrow's medical profession are formed. But classes in medical ethics and humanism alone may not lead to greater sympathy for changes in doctor-patient relations. Medical students are very discerning, and have no difficulty in determining which subjects are taken seriously by the senior faculty. Do they show concern about ethics and humanism in their lectures, their ward rounds, their other discussions and at the bedside? In other words are ethical and humanistic considerations part of their second nature, as much as a systematic history taking, observation and clinical examination?

DOMAINS OF INSTITU-TIONAL RESPONSI-BILITY

FUNDAMENTAL VALUES OF SOCIAL ACCOUNTABILITY

Relevance To Priority Hlth Problems

High Quality Of

Health Care

Cost-Effectiveness of Health care

Equity in Health Care

Services

Education

Service

Research

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The social and moral environment of society in general is also very important in influencing the humanistic and ethical behaviour in medical students. One medical educator has opined that "If we are to train humane physicians, we must begin to address ourselves as a society to the basic general education towards ethical and moral values from infancy onwards". Humanism and ethics in Medical Research and Development Social consciousness, social responsibility and social accountability have been the hallmark of the medical profession, and these characteristics apply equally to the medical researcher. Ethics and humanism can apply to the whole spectrum of research activity, from the selection of research topics, through the mode of conducting research, and to the application of results of research and development. In selecting research topics, while on the one hand researchers have the right to academic freedom of research on any subject however esoteric, it should be remembered that the researcher also has a social responsibility to try to find solutions to problems causing much of illness and suffering in the community. In other words, the researcher should have one foot in the ivory tower, but the other foot should be firmly planted on the ground.

In conducting clinical trails on patients or experiments involving human volunteers, researchers are now, or should be, under strict ethical control. Although ethics has been a fundamental part of medicine since ancient times, a heightened interest in the subject in relation to medical practice and medical research is a phenomenon of post World War II. This was a reaction against medical experiments on prisoners-of-war during that war. The Helsinki Declaration issued at the 1975 World Medical Association Meeting established standards not only for experiments on volunteers but also for clinical trials on patients undergoing treatment. The Tokyo Amendment set forth more explicitly the conditions that should govern the experiment, and adds that the results of research that do not meet these requirements should not be accepted for publication in scientific journals. Most medical research and academic institutes, including the DMR have now Ethics Committees to approve research projects involving human subjects. But the relation between the researcher and the patient or volunteer does not end once the project has been approved by the Ethics Committee. In fact, it is just the beginning. And just as the clinician should have a good 'bed-side manner' and humanistic relationship with his/her patients, so should the researcher likewise. Social responsibility and social accountability in research means that the research is not done for its own sake. It is incumbent upon the researcher to see to the utilization of his/her research results. This means that his work on this particular aspect does not end with a paper appearing in a scientific journal. The results, in a digestible form, have to reach the policy-makers, the health care decision-makers, the health professionals and the consumers.

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When it comes to development of research results it is usually taken over by business. But business it has its own objectives, profit being their main aim. So when commercial firms get into the business of developing medical products, be they drugs or appliances, it is with a profit motive notwithstanding their oft-repeated claims to the contrary. For no commercial venture will take into consideration the ethical aspects and refrain from developing a product simply because it is too expensive for the consumer who need it. And no matter how humanitarian it is, the company is unlikely to donate it to society. Just consider the recent court case in which the multinational pharmaceutical firms objected to the intention of the South African Government to purchase the much cheaper generic forms of AIDS-HIV drugs to combat the AIDS epidemic in the country. A word here about the ethics of authorship of scientific articles. There is a tendency nowadays of multiple authorship. It is of course true that a lot of research work now is teamwork. But when the list of 'authors' stretch to ten or even fifteen, it makes a mockery of the term authorship. An author, according to the Oxford Dictionary, is an originator, a writer of a book, treatise or article. Authorship implies intellectual responsibility. Too often, authorship is given or is expected for giving permission to conduct the research in one's department or hospital ward. Providing the facilities alone does not merit authorship. Similarly, providing technical assistance alone does not deserve authorship. If acknowledgement should be given to technicians, it could be provided after the names of the author/s with the note " With the technical assistance of .............." as had been suggested by some journals such as Circulation and Circulation Research. This is intellectually more honest and ethical. Conclusion Ever since man practiced medicine, there must have been those who misused the trust placed on them by patients, and had an undue interest in pecuniary rewards of the profession. For example, one Isaac Judaeus (A.D. 845-940) an Egyptian Jew who became physician to the ruler of Tunisia gave this advice to physicians: "Ask thy reward when the sickness is at its height, for being cured, the patients will surely forget what thou didst for him". What would patients and society in general think of the medical profession if they strictly followed this advice? Yet is the practice of depositing the consultation fee on making an appointment with the doctor, as occurs in some private hospitals, very much different? The above review has shown that humanism and ethics permeates through the whole fabric of the medical profession - medical practice, the organization of health services, medical research and development, and medical education. It is the very foundation on which the moral authority of the profession rests. Yet there are several influences as described previously, which shape the ethos of humanism and ethics in the medical profession in a negative or positive way. These are summarized in the next figure: (see Fig. 2)

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NEGATIVE INFLUENCES

POSITIVE INFLUENCES

FIG. 2 Positive and Negative Influences on Humanism and Ethics in the Medical Profession

The factors which have a negative influence on the ethos of humanism and ethics in the medical profession are: - Medicine becoming a business, and - Present day ethos of materialism. I have put two other factors, - Technological advances, and - Hospital based practice between the negative and positive influences because both of these factors should have beneficial effects for patient care, but as discussed previously they have unfortunately turned out to contributing to 'dehumanised' medical care.

These negative influences have shaped the present day behaviour of the medical profession. And it is into this professional milieu that the young medical graduate enters. In this context, I would like to relate to you the story about a magical

Humanism

Ethics

Technological advances

Hospital-based Practice

Medicine as a business

Present day ethos

Control & Regulation

Societal moral mores Role

Model Teaching of Medical ethics & medical education reform

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dragon who lived in a cave and which ate humans. The king sent in many a brave man into the cave to kill the dragon, but the moment the dragon was killed, blood spurting out would drench the man and he himself would become a dragon. And so the dragon lived on. In a similar vein, are we sending our young graduates, who have passed through a reoriented medical education system, into the cave of the current professional milieu, to become tainted with the ‘blood’ of professional power, privileges, and pelf, turning them yet into young dragons and dragonesses? What can be done to counter the present trend? Some positive influences have already been identified and discussed already. They are: - Control and regulation by Medical Councils or analogous bodies. - Societal moral mores, - Role models, - Teaching of medical ethics and medical education reforms. One can view the recent reforms in medical education as attempts to influence the practice of the medical profession that has to a large extent, become insular and indifferent to the health care needs of the population, and to the values of social justice and equity. Can the present reforms in medical education bring about the desired change in pattern of medical practice and the behaviour and ethos of the medical profession? Several medical educators have commented on this issue and have pin-pointed a few leads. Professor Bloom remains skeptical of the present reform efforts in medical education concentrating only on change in the curriculum and on the pedagogic methods. He argues that: “... the structure of modern medical education was established 75 years ago for the purpose of incorporating the revolution of biomedical science, and successful in that purpose, it added high-technology specialization as the main outcome goal for clinical medicine. To prepare doctors to serve the changing needs of society is repeatedly asserted as the objective of medical education, but this manifest ideology of humanistic medicine is little more than a screen for the research mission that is the major thrust of the institution’s social structure”. He goes on to add: “...The choice is clearly trending away from people-centred practice and toward the role of technical-specialist. If this observation is accurate, the explanation is not to be found in the motivation or the selection of recruits to the profession. It is in the structure of the situation of modern medicine and in the structure of its major institutions. That is where change must occur if we are not content with the way things are”. This means a major overhaul in the whole system.

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The present situation however, is not new. Human nature being such, it has occurred throughout history, as articles bemoaning the situation and exhortations to the profession appear in medical journals regularly at intervals every few years. Is it therefore cause for pessimism? Not necessarily. History has also shown that human nature can rise from the lowest ebb to heights of self-sacrifice, compassion and service. That is our hope. So where do we start? How do we slay and put to rest the magical human eating dragon?

In other words, how can we influence the working environment and the working system?

Can the profession be "regulated" for its humanistic behaviour as it is controlled for its professional conduct and ethical behaviour?

Is it a personal behaviour based on socio-religious beliefs and conduct and moral upbriging?

Can these traits be identified during student selection? Can this behaviour be inculcated during training particularly with community

oriented teaching? and finally, Does the profession really want to change? Perhaps these questions might get the attention of the Myanmar Academy of Medical Science.

Perhaps the Academy will apply its collective wisdom as to how to inject

humanism and ethics in our young medical students and graduates and thus provide yeoman's service to our people, our patients and our profession.

Perhaps the outcome would be a more compassionate humanistic and ethical

medicine in our country where the patient, as a suffering human being, will once again become the main focus of our medical care system. Before I conclude may I state that my views expressed in this Oration is in no way a sweeping indictment of the whole medical profession in our country. There are, and I personally know of a large number of doctors who are still practicing the art of curing with cetana, compassion, caring and humanism embodied in the altruistic spirit of our profession.

Finally, may I express, once again, my heartfelt thanks to the Myanmar Academy of Medical Science for this high honour conferred on me by giving me the opportunity to deliver this Oration to the Academy. Thank you.

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REFERENCES Bhatia S.L. (1977). A History of Medicine with special reference to the Orient. New

Delhi: Medical Council of India. Guthrie, D. (1958). A History of Medicine, New and revised edition, with supplement.

London, Thomas Nelson and Sons Ltd. Ko Ko, U (1987). Preventive and Social Medicine at the Crossroads. Presentation at the

National Conference of the Indian Association of Preventive and Social Medicine, Cuttack. India, 26-28 November 1987. Published as a booklet WHO/SEARO

Nyunt Wai (2000). Of Patch Adams and Goose Eggs. Myanmar Medical Journal

(Editorial); 44 Page 1., 2000. Rao, M.N. and Radhalaxmi K.K. (1960). History of Public Health in India. Calcutta, M.S.

Rao, Manthripragada House, Kakinada, Andra Pradesh (Navana Printing Works Private Ltd., 47 Ganesh Chunder Avenue, Calcutta.

Sigerist, H.E. (1941). Medicine and Human welfare, Yale University Press, 1941 Sigerist H.E. (1961). A History of Medicine. Vol 2 Early Greek, Hindu and Persian

Medicine. New York, Oxford University Press, 1961. Starr Paul. (1949). The Social Transformation of American Medicine. Nwe York: Basic

Books Inc. Publishers. World Health Organisation (1981)Global Strategy for Health for All by the year 2000-

H.F.A. Series No 3. WHO Geneva 1981. World Health Organisation (1988). Reorientation of Medical Education: Goal, Strategies

and Targets-2 SEARO; Regional Publications No. 18. Regional Office for South-East Asia, New Delhi.

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Professor U Mya Tu, M.B.,B.S, Ph.D

In appreciation of the First MAMS Oration

delivered in Yangon, 12 August 2001

Plaque of Honour presented to Professor U Mya Tu after the Oration by His Excellency the Honourable Minister of Health Major- General Ket Sein

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Page

The First M.A.M.S Oration

1

Biography of Professor U Mya Tu

2

Oration

Humanism and Ethics in Medical Practice, Health

Services,

Medical Education and Medical Research

5

Plaque of Honour presented to Professor U Mya Tu

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