BMJ 2014;348:g1503 doi: 10.1136/bmj.g1503 (Published 13 February 2014)
Page 1 of 2
Views & Reviews
VIEWS & REVIEWS PERSONAL VIEW
What should I tell my students now the law contravenes medical ethics? New Turkish legislation that restricts the emergency medical care that doctors can give and gives the state unjustified access to all patient data is incompatible with our professional code, says Murat Civaner M Murat Civaner associate professor, Department of Medical Ethics, School of Medicine, Uludag University, Bursa, Turkey “I will respect the secrets that are confided in me, even after the patient has died.”1 “A physician shall not allow his/her judgment to be influenced by personal profit or unfair discrimination.”2 “A physician shall give emergency care when it is needed, regardless of his specialty or job.”3 These national and international codes enshrine ethical values that are fundamental to our profession. But some of my students think that doctors should sometimes discriminate among patients. These ideas relate to the students’ personal values or fears about state security, for instance. I remind them of our rules and why they matter: the patient-physician relationship depends on trust. I also tell them about basic human rights, which everyone should respect.
The Turkish president has recently signed new legislation stating, “With the exception of health services in emergency situations delivered by authorised and competent persons before the arrival of formal health services, when health services become continuous, those who deliver, or commission others to deliver, health services without proper licence shall be subject to imprisonment from one to three years and an administrative fine equivalent to that of 20 000 days.”4 (This means a maximum fine of more than £500 000 (€600 000; $820 000.)
Clearly, this regulation not only conflicts with doctors’ duty to care and medical neutrality but also, in criminalising emergency care, violates the right to emergency healthcare—and it will endanger people’s lives. For example, the law suggests that a physician who is first on the scene of a major incident might have to stop treating the injured once an ambulance arrived, even if the ambulance staff could not deal with all those affected. Why introduce such a regulation? Common public opinion is that the government is reacting to the events that followed the occupation of Gezi Park in Istanbul last June.5 Subsequent police attacks on protesting civilians all over Turkey led to volunteer healthcare workers setting up temporary infirmaries in houses,
restaurants, and mosques. Some volunteers were targeted, beaten, detained, and prosecuted for helping demonstrators.6 7
However, the Ministry of Health says that it had drafted the law before that, and the health minister reportedly said, “Imagine that one put up a tent near the street to provide first aid to traffic incidents. This is not within the rule of law. The claims that the article was drafted solely to punish Gezi protesters are totally ideological and have resulted from bad intention in some circles.”8 But the new law suggests otherwise. “In the absence of healthcare personnel, limited to the duration of their mission, and after completing related training, combatant elements of the Turkish Armed Forces and staff of the Police Department for Special Operations are authorised to give emergency care,” it says.4
But the security forces have been recently implicated in violence. How can they also be expected to provide medical help and act in patients’ best interests? This law not only covers emergency care. It also grants the Ministry of Health unconditional access to all medical information: “All practices and procedures related to the delivery of health services shall be under the scrutiny of the Ministry of Health.”4 And it defines sanctions for those who refuse (a fine of 1% of the previous month’s gross income). This complements legislation from 2013, which gave the ministry the authority to collect, process, and share all patient information, including personal information such as contact details held by public and private healthcare institutions and workers without exception.9 Another part of the Turkish penal code, dated 2004, states, “A healthcare worker will be punished by up to one year imprisonment if she witnesses any sign of crime and does not report it immediately to the authorities,”10 requiring doctors to breach patient confidentiality without any justification. All this makes my job much harder because I need to help my students understand why keeping personal information
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BMJ 2014;348:g1503 doi: 10.1136/bmj.g1503 (Published 13 February 2014)
Page 2 of 2
VIEWS & REVIEWS
confidential is crucial to our profession. I should start with why medicine should not be a tool for exerting political pressure and then emphasise that our profession’s values are universal and distilled from centuries of painful experience. They cannot be bent according to political agendas, and doctors must stand firm to defend them, as the Turkish Medical Association has done in its response: “We will continue to protect the honour of our profession.”11 Now we hope that the Constitutional Court will annul this law. Nevertheless, this case shows the importance of all those rules of professional morality in guiding the way to ensuring patients’ best interests when the law contravenes medical ethics. As the World Medical Association insists, “A physician shall be dedicated to providing competent medical service in full professional and moral independence, with compassion and respect for human dignity.”2 Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
1 2 3 4 5 6 7 8
9 10 11
World Medical Association. Declaration of Geneva. www.wma.net/en/30publications/ 10policies/g1/. World Medical Association, International code of medical ethics. www.wma.net/en/ 30publications/10policies/c8/. Turkish Medical Association. Physician professional code of ethics. www.ttb.org.tr. The law on changing of some laws and the decree on the organisation and duties of the Ministry of Health and its institutions. Nr 6514. Official Gazette 18 January 2014. Civaner M. Protests in Turkey, state violence, and how doctors are helping: it’s about much more than a park. BMJ 2013;346:f3789. Turkish Medical Association. Report on the assessment of health problems in persons exposed to chemical riot control agents. 2013. www.ttb.org.tr/kutuphane/kimyasalgosteri_ en.pdf. Iacopino V, Nathanson V, Kloiber O, Chrispin E, Heisler M, Dunevant D, et al. Attacks on medical personnel in Turkey. BMJ 2013;347:f4933. Health regulation planned before Gezi protests, Turkey’s health minister says. Hurriyet Daily News 2013 Dec 11. www.hurriyetdailynews.com/health-regulation-planned-beforegezi-protests-turkeys-health-minister-says.aspx?pageID=238&nID=59389& NewsCatID=341. The law on changing of some laws and decrees. Nr 6495. Official Gazette , 12 July 2013. Turkish penal code. Nr 5237. 2004. www.tbmm.gov.tr/kanunlar/k5237.html. Turkish Medical Association. Medicine will continue to maintain the dignity of the profession. Press release, 9 December 2013. www.ttb.org.tr/index.php/Haberler/hekimlik-4190.html.
Cite this as: BMJ 2014;348:g1503 © BMJ Publishing Group Ltd 2014
Provenance and peer review: Not commissioned; not externally peer reviewed.
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
Page 1 of 2
Views & Reviews
VIEWS & REVIEWS PERSONAL VIEW
What should I tell my students now the law contravenes medical ethics? New Turkish legislation that restricts the emergency medical care that doctors can give and gives the state unjustified access to all patient data is incompatible with our professional code, says Murat Civaner M Murat Civaner associate professor, Department of Medical Ethics, School of Medicine, Uludag University, Bursa, Turkey “I will respect the secrets that are confided in me, even after the patient has died.”1 “A physician shall not allow his/her judgment to be influenced by personal profit or unfair discrimination.”2 “A physician shall give emergency care when it is needed, regardless of his specialty or job.”3 These national and international codes enshrine ethical values that are fundamental to our profession. But some of my students think that doctors should sometimes discriminate among patients. These ideas relate to the students’ personal values or fears about state security, for instance. I remind them of our rules and why they matter: the patient-physician relationship depends on trust. I also tell them about basic human rights, which everyone should respect.
The Turkish president has recently signed new legislation stating, “With the exception of health services in emergency situations delivered by authorised and competent persons before the arrival of formal health services, when health services become continuous, those who deliver, or commission others to deliver, health services without proper licence shall be subject to imprisonment from one to three years and an administrative fine equivalent to that of 20 000 days.”4 (This means a maximum fine of more than £500 000 (€600 000; $820 000.)
Clearly, this regulation not only conflicts with doctors’ duty to care and medical neutrality but also, in criminalising emergency care, violates the right to emergency healthcare—and it will endanger people’s lives. For example, the law suggests that a physician who is first on the scene of a major incident might have to stop treating the injured once an ambulance arrived, even if the ambulance staff could not deal with all those affected. Why introduce such a regulation? Common public opinion is that the government is reacting to the events that followed the occupation of Gezi Park in Istanbul last June.5 Subsequent police attacks on protesting civilians all over Turkey led to volunteer healthcare workers setting up temporary infirmaries in houses,
restaurants, and mosques. Some volunteers were targeted, beaten, detained, and prosecuted for helping demonstrators.6 7
However, the Ministry of Health says that it had drafted the law before that, and the health minister reportedly said, “Imagine that one put up a tent near the street to provide first aid to traffic incidents. This is not within the rule of law. The claims that the article was drafted solely to punish Gezi protesters are totally ideological and have resulted from bad intention in some circles.”8 But the new law suggests otherwise. “In the absence of healthcare personnel, limited to the duration of their mission, and after completing related training, combatant elements of the Turkish Armed Forces and staff of the Police Department for Special Operations are authorised to give emergency care,” it says.4
But the security forces have been recently implicated in violence. How can they also be expected to provide medical help and act in patients’ best interests? This law not only covers emergency care. It also grants the Ministry of Health unconditional access to all medical information: “All practices and procedures related to the delivery of health services shall be under the scrutiny of the Ministry of Health.”4 And it defines sanctions for those who refuse (a fine of 1% of the previous month’s gross income). This complements legislation from 2013, which gave the ministry the authority to collect, process, and share all patient information, including personal information such as contact details held by public and private healthcare institutions and workers without exception.9 Another part of the Turkish penal code, dated 2004, states, “A healthcare worker will be punished by up to one year imprisonment if she witnesses any sign of crime and does not report it immediately to the authorities,”10 requiring doctors to breach patient confidentiality without any justification. All this makes my job much harder because I need to help my students understand why keeping personal information
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g1503 doi: 10.1136/bmj.g1503 (Published 13 February 2014)
Page 2 of 2
VIEWS & REVIEWS
confidential is crucial to our profession. I should start with why medicine should not be a tool for exerting political pressure and then emphasise that our profession’s values are universal and distilled from centuries of painful experience. They cannot be bent according to political agendas, and doctors must stand firm to defend them, as the Turkish Medical Association has done in its response: “We will continue to protect the honour of our profession.”11 Now we hope that the Constitutional Court will annul this law. Nevertheless, this case shows the importance of all those rules of professional morality in guiding the way to ensuring patients’ best interests when the law contravenes medical ethics. As the World Medical Association insists, “A physician shall be dedicated to providing competent medical service in full professional and moral independence, with compassion and respect for human dignity.”2 Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
1 2 3 4 5 6 7 8
9 10 11
World Medical Association. Declaration of Geneva. www.wma.net/en/30publications/ 10policies/g1/. World Medical Association, International code of medical ethics. www.wma.net/en/ 30publications/10policies/c8/. Turkish Medical Association. Physician professional code of ethics. www.ttb.org.tr. The law on changing of some laws and the decree on the organisation and duties of the Ministry of Health and its institutions. Nr 6514. Official Gazette 18 January 2014. Civaner M. Protests in Turkey, state violence, and how doctors are helping: it’s about much more than a park. BMJ 2013;346:f3789. Turkish Medical Association. Report on the assessment of health problems in persons exposed to chemical riot control agents. 2013. www.ttb.org.tr/kutuphane/kimyasalgosteri_ en.pdf. Iacopino V, Nathanson V, Kloiber O, Chrispin E, Heisler M, Dunevant D, et al. Attacks on medical personnel in Turkey. BMJ 2013;347:f4933. Health regulation planned before Gezi protests, Turkey’s health minister says. Hurriyet Daily News 2013 Dec 11. www.hurriyetdailynews.com/health-regulation-planned-beforegezi-protests-turkeys-health-minister-says.aspx?pageID=238&nID=59389& NewsCatID=341. The law on changing of some laws and decrees. Nr 6495. Official Gazette , 12 July 2013. Turkish penal code. Nr 5237. 2004. www.tbmm.gov.tr/kanunlar/k5237.html. Turkish Medical Association. Medicine will continue to maintain the dignity of the profession. Press release, 9 December 2013. www.ttb.org.tr/index.php/Haberler/hekimlik-4190.html.
Cite this as: BMJ 2014;348:g1503 © BMJ Publishing Group Ltd 2014
Provenance and peer review: Not commissioned; not externally peer reviewed.
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
