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LETTER TO THE EDITOR
Year : 2020  |  Volume : 68  |  Issue : 6  |  Page : 1231-1232

More than meets the eye: Bioethics in ophthalmology


Department of Glaucoma, Sita Lakshmi Glaucoma Center, Anand Eye Institute, Hyderabad, Telangana, India

Date of Web Publication25-May-2020

Correspondence Address:
Dr. Tarannum Mansoori
Department of Glaucoma, Sita Lakshmi Glaucoma Center, Anand Eye Institute, Habsiguda, Hyderabad - 500 007, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1963_19

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How to cite this article:
Mansoori T. More than meets the eye: Bioethics in ophthalmology. Indian J Ophthalmol 2020;68:1231-2

How to cite this URL:
Mansoori T. More than meets the eye: Bioethics in ophthalmology. Indian J Ophthalmol [serial online] 2020 [cited 2024 Mar 28];68:1231-2. Available from: https://journals.lww.com/ijo/pages/default.aspx/text.asp?2020/68/6/1231/284829



As ophthalmologists, we often face challenging ethical dilemmas in our day-to-day practice. During my fellowship, I came across two siblings who required enucleation/exenteration for retinoblastoma, but the parents insisted that the male child should be operated to save his life and the female child can be left alone, as she would be a liability in the future!! I have seen cases, where a female patient is diagnosed with retinitis pigmentosa and she insists that her husband should not be told about her ocular condition. I have also come across cases where the husband files for legal separation after learning about his wife's disease. This brings in the principle of patient autonomy, as the patient decides whether to tell the family members or not.

We all follow the four major ethical principles in healthcare: respect for patient autonomy, beneficence, nonmaleficence, and justice.[1] Autonomy is respecting the decision-making ability of the patient and it applies only if the patient is capable of making an informed decision. It is the physician's responsibility to provide unbiased information to the patient regarding the available treatment options, discuss the risks and benefits of each intervention, the option of refusing the treatment, and its consequences. Physicians also have a right to oppose the patient's choice, particularly, if they believe it is harmful for the patient to refuse the proposed treatment. In the present era, because of the online access to medical information, the patients are aware of the treatment options and sometimes come with the diagnosis of their own ocular condition. Still, most of our patients trust us to make the correct decision for them regarding the treatment and thus our responsibility to the patient increases. Beneficence is the duty of the physician, that they will do the best for the patient. Nonmaleficence is the avoidance of harm and is a duty that we owe to everyone (whether our patients or not.) Primum non nocere ( first do no harm) is one of the most important medical ethical principles.[2] Justice has four main aspects, namely, distributive justice (all patients should have access to the same healthcare), respect for the law, retributive justice, and patients' rights (expecting standard healthcare).

New innovations in the medical science are intended to help the patient but they may also have an associated financial or conflicts of interest. Before introducing new innovations in the clinical practice, one must not forget their responsibility to the patient. We should discuss the innovative nature of the proposed new treatment, past experience of others, our limited experience with the procedure, and also disclose the other available treatment options. In doing so, we take the ethical implications of our actions. One must ensure that advertising or marketing of “new technology” remains fair. Public information about the new technology and surgeons' credentials should be free of misleading statements, as significant omissions can result in patient's unrealistic expectations.

Another area where the ethical issues are discussed is the clinical and basic research. The hospital ethics committee plays a vital role to ensure patient's protection and balance it with the need for the research. The World Medical Association has developed the Declaration of Helsinki as a statement of ethical principles for the medical research involving human subjects, including research on identifiable human data and it encourages researchers to adopt these principles.[3]

American Academy of Ophthalmologists has shaped the professional conduct across the globe through a code of ethics.[4],[5] Some of these are: Any medical or surgical procedures shall be preceded by appropriate informed consent, an ophthalmologist shall respect the confidential physician-patient relationship and safeguard confidential information consistent with the law, fees for ophthalmological services must not exploit patients or others who pay for the services. It is the responsibility of an ophthalmologist to act in the best interest of the patient and maintain integrity in clinical and basic research. The responsibility of the ophthalmologist extends not only to the individual but also to the society as a whole and communications to the colleagues or public must be truthful and accurate. International Council of Ophthalmology document comprises a similar set of moral principles and standards to guide the ophthalmologists.

In most of the training institutes, eye camps are organized to teach cataract surgery to the trainee ophthalmologists. Should the patients be informed that a traineeophthalmologist would be performing the surgery? Who is responsible (trainee or the supervising surgeon) for the complications, if any? Wet lab training for the trainees, thorough preoperative workup, patient selection, and adequate supervision during surgery is essential. During the training, the mentors should teach the residents as to how to handle the ethical issues and the concept that the truth-telling is an integral part of our professional duty. The National Board of Examinations and UNESCO Chair in Bioethics (Haifa) have taken the initiative to conduct training in Bioethics and have proposed a curriculum where bioethics, communication, quality, and safety are being introduced as a mandatory learning objective for the postgraduate teaching program.

Let's look at a situation, where a 55-year-old patient is diagnosed with advanced glaucoma in both the eyes and ophthalmologists advise him against driving, but the patient refuses the suggestion. In view of public welfare, shall the ophthalmologist ensure that his vehicle driving license is revoked? There are ethical issues of protecting the patient's confidentiality, protecting society, and protecting the patient from the potential harm if the patient continues to drive. One has to balance the patient's autonomy and beneficence in making the correct decision.

One of my mentors once rightly said that there are no “right answers” in ethics but the best answer for a situation is often found by using the correct judgment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 7th ed. Oxford, UK: Oxford University Press; 2012.  Back to cited text no. 1
    
2.
Logar T, Le P, Harrison JD, Glass M. Teaching corner: “First do no harm”: Teaching global health ethics to medical trainees through experiential learning. J Bioeth Inq 2015;12:69-78.  Back to cited text no. 2
    
3.
World Medical Association. World medical association declaration of Helsinki: Ethical principles for medical research involving human subjects. JAMA 2013;310:2191-4.  Back to cited text no. 3
    
4.
Bettman JW. The development of the code of ethics for the American academy of ophthalmology. Surv Ophthalmol 2000;44:357-9.  Back to cited text no. 4
    
5.
Academy advisory opinions on the code of ethics. American academy of ophthalmology. Ophthalmology. 1986;93:709-16.  Back to cited text no. 5
    




 

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