How do you analyze the present situation of medical ethics in the Arab Region?

Medical Ethics in the Middle East is more or less a resurrection in so many ways. Indeed the first sources of medical ethics in particular arose from this region. In the 9th century, Al Tabari described the codes of ethics that a physician should abide by in his The Paradise of Wisdom (Ferdous al Hekmat). In Spiritual Medicine, Al Rhazes clearly stipulated the importance of the physician’s commitment to principles of ethics. Moral guidance to the physician can also be found in the books of Avicenna and others. Yet, perhaps the most significant and detailed book dealing with medical ethics was written in the 10th century AD by Ishaq bin Ali Al-Ruhawi in his Adab al-Tabib (Ethics of a Physician) translated later by the American Philosophical Society in 1967. However, these were all mostly religiously driven and thus Islamic in spirit. Eventually, these thoughts somehow collapsed and a new paradigm shift occurred (I will not go into details as to the possible explanation for this shift as explanations can sometimes be read as justifications and I certainly do not want that) and a schism was created between medicine and the rest of the arts which were looked at as intruders. This marked the collapse of official medical ethics as we know it.

However, the culture of this particular area allows for some form of innate medical ethics governed by compassion and care particularly when the physician has a strong moral compass that can stand in the face of the different lures that can present themselves to him/her. Lately however, we can say that the resurrection began. The Arab world is now, perhaps more than ever before, accepting of medical ethics and its importance in the profession of medicine.

Currently, the prevailing trends in medical ethics in the Arab world focus on religious ethics and a more or less rudimentary form of research ethics. Clinical medical ethics which is primarily patient-centered is only budding and, in a way, still in the pediatric intensive care unit. While many principles and practices can be adopted from the codes and principles of medical ethics as developed in the West, not everything can, nor should, be adapted to the Middle Eastern culture, and there will inevitably be variations and core nuances dictated by the local culture.

Of course, the medical profession being what it is, there are core universal values that apply. However, the peripheral values surrounding the core are dynamic by nature. At the American University of Beirut Medical Center and Faculty of Medicine, the Salim El-Hoss Bioethics and Professionalism Programme (soon to be a Center) has been a pioneer in introducing the culture of medical ethics (sensitive to the local culture) and its clinical counterparts in Lebanon through the medical curricula, rounds, workshops, committees and others as well as in the Arab region. We have currently started seeing a paradigm shift and a culture change in that direction.

In your opinion, how will the situation likely evolve over the next five years?

It is not that easy to tell as we cannot generalize. However, I can safely say that the topic is now a requirement in the curricula of most medical schools in the Middle East. The interest in medical ethics (or bioethics) has been developing rapidly these last few years and we now have medical students and physicians publishing in the area and interested in pursuing their postdoctoral studies in this field.

It is important to create a general culture that accepts medical ethics (and bioethics) while adapting the core principles to our culture. After all, medical ethics is not an add-on to medicine: it is part and parcel of the profession.

What are the structural long-term perspectives?

Tough question precisely because medical technology is developing at a rapid, if not mad, pace and market forces are attacking the medical sectors from almost every imaginable angle. Medical technology (where what can be done is not always curbed with what ought to be done) is constantly creating new opportunities filled with a plethora of moral conundrums which might make it difficult to grapple with the new developments in countries that are still not fully at ease with the core and are not yet immune to the possible lures that this technology might bring.

"It depends" is not an answer I like to give. But of course, the main force against the possible dilution of the practice of medical ethics is the character of those practicing. Teaching is never enough. It has to be coupled by role modeling and the formal curriculum needs to go hand in hand with the hidden and informal ones. I will even add that admission to medical school needs to be more sensitive to character. It is not the GPA of the student that judges if he/she can be a physician (as opposed to a skilled technician or practitioner). It is his/her character which cannot be created anew (as Aristotle said, we cannot teach a stone to fly upwards) but can be directed and molded.

                        

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Thalia Arawi is Founding Director of the Salim El-Hoss Bioethics and Professionalism Program (SHBPP) at the American University of Beirut Faculty of Medicine and Medical Center, and the first Arab to specialize in bioethics with two PhDs. She is also the Clinical Bioethicist and Clinical Ethics Consultant at AUBMC and the Vice Chair of the Medical Center Ethics Committee there. Dr. Arawi is the first Arab member to be appointed on the board of the International Association of Bioethics, and founding member and Advisory Board member of the Bioethics Network on Women's Issues in the Arab Region and has been recently elected as the First Chair of the Network.

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