Slovakia struggles with ethics in a health system undergoing rapid change
16.6.2006 - Katarina Richterova

Health care workers have been stirring up public debate having gone into their first major strike in history, leaving several hospitals with emergency care only. The strike could be called a success as poorly paid health workers will get a 20% salary increase. But wages are only part of the story. Big changes are being made to Slovakia's health sector with the reformers describing patients as customers. Katerina Richterova looks into the ethics of health care in a system undergoing dramatic change:

The waiting room at the doctor's is not the most pleasant of places to be stuck in. Crammed in with fifteen other patients, the nurse comes out of the door and asks: Who is here for the abortion? It certainly doesn't make you feel at ease. Or imagine being examined by a doctor while another patient is in the same room, getting undressed and ready for an examination. You're probably thinking this is just a bad joke, but in some Slovak health care institutions it is the reality.

Cases like this should not happen at all, since doctors and other health care professionals have a code of ethics that they should follow. However one does hear about such incidents quite often raising the question: where are the ethics in health care?

"The law states that doctors should be experts, with a human approach and respecting the patient's dignity. In case a patient complains about the doctor, or wants to change to a different doctor, it should not be held against the patient."

Eva Vyvodova, head of the office that overlooks the provision of health care quoting the code of ethics. These are the rules, but are they always kept to? In a little more than one year, the office that overlooks the provision of health care investigated over 2,000 complaints filed by patients against health care professionals.

"We get complaints about inadequate provision of health care. In average we get approx. 50 phone calls per day, from patients mainly complaining about health care personnel not respecting visiting hours or fees."

The office has not received any complaints about not respecting ethical principals or discretion.

"Maybe such cases do happen but people don't talk about them. Maybe in a year's time the number of complaints will be different than now."

Another body monitoring the work of doctors and nurses is the Slovak Medical Chamber. Jarmila Ambrusova is the chairwoman of the Slovak Medical Chamber:

"Last year we received 170 complaints about the provision of health care of which 2 were about inadequate privacy in health care facilities."

For non-ethical behaviour doctors can pay a fine starting from 50 000 SKK, which is some 1,200 Euros, certainly having no top limit. As the number of complaints to the bureau as well as to the medical board indicates, more and more patients seem to be aware of their rights when going to the doctor's. Eva Vyvodova:

"I think that doctors are being more careful and maybe also thanks to the Medical Chamber, that is their controlling body. They are more careful also in handling the patient, because now they see that patients are no longer afraid to speak out."

"The legal awareness of doctors has increased. They know that the issue of ethics is very frequently discussed and closely watched. It is also in their interest not to lose patients and that is why they are trying to provide them with a pleasant environment and also ensure them privacy."

... concludes Jarmila Ambrusova, chairman of the Slovak Medical Chamber. Statistics suggest that there are more complaints from patients from bigger towns, where there are also more doctors and patients, but this does not mean that in smaller towns or villages the situation is better. On the contrary, says Jarmila Ambrusova ....

"Mainly in cases of small villages, where there is only one doctor, he or she feels that there is no competition. Where there is bigger competition, doctors try to provide patients with the best service possible."

Ethics in medicine have only been taught at the Faculty of Medicine in Bratislava since 1993. This means that for 40 years, medical professionals were not taught ethics at all. This could be one of the possible explanations for the current situation. Those doctors in practice right now have not learned at school how important and strategic it is to communicate well and ethically with a patient. As Maria Mojzesova, lecturer of medical ethics at the faculty of medicine in Bratislava says, educating medical students in the area of ethics is important. But in the end it comes down to the individual, his character and inner beliefs.

"Their inner abilities to be humane and have empathy with the patients and their families."

"Sometimes it just becomes routine because there are many patients..."i

... says a young doctor, judging from her own observations. With the new generation of medical professionals, can we look towards a brighter future, in terms of being treated well at the doctor's?

"I hope that in the future, through young medical professionals, medicine will be better and more ethical in our country."

Maria Mojzesova, lecturer of medical ethics says not only knowledge and skills make a good medical professional, but it is the right approach to a patient that makes the difference. However, with all the things going on in the health care sector in Slovakia today, many say respecting ethics is not a priority right now. Patients, unlike doctors, did not go on strike, but this doesn't have to mean that they don't want a change in the way they are treated.

Poland's abortion dilemma
16.6.2006 - Iwona Lejman

A Polish woman who was refused an abortion despite doctors' warnings that giving birth could damage her eyesight has taken Poland to the European Court of Human Rights in Strasbourg. She claims that the country failed to protect her rights under its strict abortion law. Poland has one of the most restrictive abortion laws in Europe, and abortions are only very rarely approved. Iwona Lejman looks at the ethical issues confronting Poland's doctors:

While for most mothers giving birth is a blessing, for some it is a question of life and death. A recent case has led to doubts as to whether this is taken into consideration in Poland. A single woman from Warsaw became pregnant, but because of her serious eyesight condition, she knew that by having a baby she could go blind. Alicja Tysiac applied for the right to terminate her pregnancy on health grounds, but she was refused. As a result, she has nearly lost her eyesight. She argues that due to the doctors' refusal, her private life collapsed, she received inhuman and degrading treatment and was discriminated on the basis of her sex and disability.

Poland is a predominantly Catholic country. Its abortion law is one of the strictest in Europe and termination is illegal except when there's a threat to the mother's or the fetus's health or when a woman was subjected to rape. However, in practice, the law is hardly ever observed. All in all there are around 200 abortions a year in Poland, according to Wanda Nowicka of the Federation for Women and Family Planning:

"This law is even more restrictive in practice than on paper. In the last few years that the law has been in place, we have observed that a pregnant woman does not enjoy the same right to health as a woman who is not pregnant. A pregnant woman is immediately treated as a potential mother - when she needs an abortion, she is very often denied it and when she continues the pregnancy she does not get treatment in order not to hurt the fetus. So, basically, the life of the fetus is seen as superior to the mother's life or her health."

When Alicja Tysiac - now 35 - discovered she was pregnant for the third time, she consulted doctors in February 2000 who told her that she faced a serious risk to her eyesight if she carried the pregnancy to term. However, they refused to grant her an abortion certificate. Following the delivery by Caesarian section her eyesight deteriorated abruptly due to what was diagnosed as retinal hemorrhage. The woman cannot see objects more than 1.5 metres away. She has registered as disabled, is dependent on constant help and unable to raise children. Alicja tells me her story looking through thick and powerful glasses:

"I was told that with my health condition I should be under constant care, but the fact is that I have to look after my three children and am not getting help from anyone. With my pension of 140 euros a month I can't make ends meet. I can't even afford medicines that my son needs."

Alicja Tysiac lodged a criminal complaint against the Warsaw hospital's chief obstetrician, but the district prosecutor decided there was no link between the doctor's decision and her worsening vision.

"Before the case started I was told it had already been lost."

Now she hopes that the European Court of Human Rights will have the final word in such abortion cases in Poland:

"I am happy that this case will be discussed so widely now and I hope it will make doctors think twice before they next refuse an abortion to a pregnant woman in my condition."

Wanda Nowicka of Federation for Women says pregnant woman are not treated on equal terms with other patients. Since Poland freed itself from communist rule there has been a lot of pressure from church circles. She claims that doctors are being hypocritical.

"Certainly, the role of the Roman Catholic Church is instrumental in promoting this kind of an attitude within the medical community and among lawyers in Poland. However, apart from that, I think it is linked to a certain hypocrisy of the medical community. They pretend that they are very moral by not providing abortions but, at the same time, many of them perform 'underground abortions' in secret for large amounts of money."

Doctors themselves look at the matter from another angle. Krzysztof Niemiec, a gynecologist, stresses that the situation is particularly difficult for those who as Catholic doctors face a real moral and ethical dilemma, not to mention the pressure of the environment:

"I think we are overestimating the influence of the Catholic Church and the problem of abortion. The situation in Poland today is not convenient for women but it is very convenient for many organizations, the Church, politicians, and for gynecologists because they can make abortions illegall. That is why I think the situation won't change soon."

The European Court of Human Rights obviously cannot change the Polish abortion law, but it could rule that Alicja Tysiac's rights have been violated.

Hospices in Slovenia - breaking the taboos around death
16.6.2006 - Ksenija Samardzija-Matul

The Slovenian Hospice is a non-governmental, non-profit humanitarian organisation caring for patients - and the families of patients - facing a life-threatening illness. It tries to meet the physical, emotional, and social needs of the person who is dying and of their loved ones. It's a free service and helps people at home or in hospital. Ksenija Samardzija-Matul visited the hospice in Slovenia's second largest city - Maribor:

Breaking the taboos around death is another issue tackled by hospices in Slovenia with the aim of shaping a more natural relationship to death - something that was normal when people were more closely connected to nature. Staff of hospices turn to children by visiting schools and preparing workshops entitled 'circle of life' where pupils can talk about disease, severe illness and death, and there are training courses for the broader public on how to talk to dying people and how to cope during the process of mourning. Breaking taboos is extremely important for the professional staff as well, because they can only help if they overcome their fears and their denials to develop a true and close human bond. Therefore the staff itself has regular supervised sessions where they can talk about their experience and the emotional problems they encounter during their work.

The driving force behind hospices is the desire to transform the experience of dying. The terminally ill are comforted by volunteers who are trained in how to talk and how to listen to them. Professional medical care is given and symptom relief provided. In what way the medical team, social workers and volunteers help depends on the patient's individual wishes and family's needs. I visited the hospice in Maribor and talked to its director, Majda Brumec. I immediately felt comfortable in the friendly rooms where many family members meet with the staff of the hospice to talk about their fears. I asked Majda Brumec how families come into contact with the hospice:

"The patient's physician, friends or other family members advise them to contact us. People in distress need either emotional help or organizational support at home and often the family members are not sure whether or not they are able to take care of the dying. The nurse visits the patient whenever he or she is in need; it depends on the condition of the patient. In the last days a nurse will go and visit the dying patient twice a day if necessary. A volunteer usually spends 8 to 10 hours per week with the family."

Hospices regard dying as a normal process and neither hasten death nor prolong life artificially. The goal of the hospice team is to be sensitive to the special requirements of each individual and family. Care for the terminally ill typically involves a physician, a nurse, a social worker and a volunteer. The hospice nurse makes regularly scheduled visits to the patient, social workers provide assistance with practical and financial concerns as well as emotional support. However the work of the volunteers should not be underestimated.

I talked to Vesna Zigon one of the volunteers in the hospice in Maribor and asked her about her motivation to work for the hospice:

"The motive for me to be a volunteer at the hospice is actually to help people. I like people and so I want to be close to them. Disease and death are things that we try to avoid in everyday life and I believe that it is important to be human to fellow men during their hardest moments."

It is obvious that not everyone can become a volunteer. The selection has to be carefully made and the person wanting to become a volunteer must be mentally stable and strong. I asked Vesna whether she knew she would be capable of helping:

"Before I started the training programme for volunteers I was not sure that I will be able to do it. But my confidence grew with every week. It is a learning process and a form of personal growth, and of course it changes ones personal relationship to illness, dying and death, as well as ones attitude towards life itself as the basic philosophy of hospice is life."

The training of volunteers is a gradual and gentle process stretching over 11 weeks. The future volunteers meet once a week to discuss several issues: first they have to clarify how they themselves feel towards dying, death and life, and then they learn how to communicate and listen to people. At the end of the training process they have to decide whether they feel strong enough to be a volunteer working with dying patients and supporting their families.

The staff of the hospice only take care of the patient in the last months of his or her life. At the point when the patient's physician decides that the illness can no longer be actively treated, the hospice takes over. It is important not just to take care of the dying is, but also to help the family members who are under a lot of stress. Majda Brumec the head of the hospice in Maribor explains:

"We are aware of the needs of the family members and often they need to talk to someone with the patient being present. They need a lot of support and we let them know they will be able to manage the situation. The care for the family starts even before the patient has died. There is mourning before the actual death. We let them mourn we listen to them, we do not teach or direct them how they should behave."

The hospice staff also provides help for the families after their family member has died, by visiting them and offering programmes of mourning and support groups, which meet once a month, or they offer individual counselling. A fact that is often forgotten is that children mourn, too. Hospices in Slovenia provide for children's needs by organizing creative workshops and individual counselling. Twice a year they even organize a camp for children and this has been quite a success: Majda Brumec:

"These camps, which are well received, help children, who are often neglected in the process of mourning. We forget that children mourn, not only when they loose a parent but also when they loose their grandparents, a brother or a friend."

At the end of our talk I asked Majda Brumec if it is at all possible to be prepared for death:

"It would be an illusion to think that we can prepare ourselves or every patient for death but we allow them to go their own way in coping with dying and death and this is our major task. Older people in general are more prepared as death is a logical consequence to them, and also for the staff it is easier to accept."

Stem cell research in Hungary
16.6.2006 - Sandor Laczko

Experts believe over two billion people suffer from diseases that may eventually be treated - or even cured - with stem cells. These include heart disease, diabetes, and certain types of cancer. But research in this field is often impeded by ethical concerns. Sandor Laczko of Radio Budapest looks at the situation in Hungary:

Stem cell research in Hungary is not an issue the general public is concerned about. The only difference of opinion is - not surprisingly - between the approach of most scientists and that of the Catholic Church. Legislation on this field in this country is quite permissive as you can hear from Laszlo Bito, a Hungarian professor emeritus at the Columbia University in the United States:

"It's probably in the middle of the range of the United States where every state has different laws. In Hungary, there are no specific things about what researchers can do."

When the issue of stem cell research comes up in Hungarian intellectual circles, the debate is usually about whether it is a scientific or a moral issue. Immunologist research professor Balazs Sarkadi, who was appointed by the Bench of Hungarian Catholic Bishops to talk about this matter, had this to say:

"It's mostly a scientific issue because we need new technologies and new methods and it will be a major part of the medical treatment. But, of course, - at the same time - it is also a moral issue, especially because of embryonic stem cells. The Catholic Church recognises the fertilised egg as a human being. After the first divisions, it's already a human being - in the view of the Catholic Church.

So, the Catholic Church opposes research on embryonic stem cells because those cells are considered to constitute a human being. Professor Bito, a widely recognised physiologist by profession, does not share this view:

"Personally, I have the belief that becoming human is a slow process, and that fertilisation is just one step, implantation is another step, just as the development of the placenta is. But the main step is when they take the first breath of air, because that first breath of air is when the circulation changes from a parasitic kind of circulation to a free-living, free-breathing human being."

While sticking to the Catholic moral point that research on embryonic stem cells is wrong, strangely enough, Professor Balazs Sarkadi acknowledges that his institute does carry out research on cells derived from embryos.

"There is some research like in our institute but we are using already prepared embryonic stem cell lines - there is no real ethical concern there."

So Professor Sarkadi seems to be arguing that stem cell research is acceptable as long as the removal of the cell from embryos is done by somebody else. One final aspect of the Hungarian debate about stem cell research comes from a linguistic peculiarity of the Hungarian language itself. Professor Bito explains:

"One interesting aspect that's different in Hungary is the name of the stem cell. We call it "ossejt", the 'os' prefix means 'ancient', 'old'. For example, "oserdo" is 'ancient forest'. So, that word 'ossejt' has a very different connotation, and is a little bit mystical, while 'stem cell' is good and straightforward. 'Ossejt' sounds like it came from Adam and Eve or something of that sort."