Editorial
Medical ethics and ophthalmology
Ética médica y oftalmología
J. Jiménez Benito
Servicio de Oftalmología, Hospital Universitario de Burgos, Burgos, Spain
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(B) Fundus autofluorescence evidenced a slightly diminished signal that corresponds to detachment areas associated to linear hyperfluorescence that translated hyperpigmentation. (C) No signs of choroidal neovascularization can be observed in fluorescein angiography. (D) Same with indocyanine green. (E) SD-OCT images show the presence of initial low density subretinal fluid. (F) After 9 months follow-up, 3 intravitreal injections of ranibizumab and one of triamcinolone acetonide, SD-OCT showed complete subretinal fluid resolution. Best corrected visual acuity increased from the initial 0.25–0.50 at the final visit.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Cuesta-Lasso, A. Vieira-Barros, R. Dolz-Marco, M.J. Roig-Revert, J. Badal, L. Amselem, M. Díaz-Llopis, R. Gallego-Pinazo" "autores" => array:8 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Cuesta-Lasso" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Vieira-Barros" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Dolz-Marco" ] 3 => array:2 [ "nombre" => "M.J." "apellidos" => "Roig-Revert" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "Badal" ] 5 => array:2 [ "nombre" => "L." "apellidos" => "Amselem" ] 6 => array:2 [ "nombre" => "M." "apellidos" => "Díaz-Llopis" ] 7 => array:2 [ "nombre" => "R." "apellidos" => "Gallego-Pinazo" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0365669116301940" "doi" => "10.1016/j.oftal.2016.10.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365669116301940?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579417300075?idApp=UINPBA00004N" "url" => "/21735794/0000009200000003/v1_201703010038/S2173579417300075/v1_201703010038/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Medical ethics and ophthalmology" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "99" "paginaFinal" => "100" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "J. Jiménez Benito" "autores" => array:1 [ 0 => array:3 [ "nombre" => "J." "apellidos" => "Jiménez Benito" "email" => array:1 [ 0 => "jjimenez@saludcastillayleon.es" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Oftalmología, Hospital Universitario de Burgos, Burgos, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ética médica y oftalmología" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The medicine we practice originates in ancient Greek culture and presumably derives from a series of books written by various authors in the 4<span class="elsevierStyleSup">th</span> and 5<span class="elsevierStyleSup">th</span> century BC, known as <span class="elsevierStyleItalic">Corpus Hippocraticum</span>. The main characteristic of these medical treatises is that they attribute the origin of diseases to natural causes, separating medicine from religion or supernatural beliefs.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> An additional and striking characteristic of the <span class="elsevierStyleItalic">Corpus Hippocraticum</span> is the inclusion of behavior patterns that the physician must fulfill in order to adequately practice the art, known as the Hippocratic Oath. This text involves assuming the paradigm of a profession—the medical profession—that makes an oath in which ethics plays an essential part in the satisfactory development of professional activity.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Arab texts also include references to what we could define as the ethical behavior of medics with their patients which, beyond technical issues, proposes cordiality and respect for the patient, which are not included in Greek medicine. Ali ibn Isa (940-1010), an Arab medic, made the following annotation when describing cataract surgery: «while the needle is in the eye of the patient, speak kind words to diminish his anxiety …». These comments, never previously recorded by other medics,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> demonstrate an attitude of respect and compassion for patients that will be incorporated in ophthalmology many centuries later and which, unfortunately, is not always present in our activity. The texts of said medic also included the recommendation of avoiding creams or ointments that could damage the eye, in accordance with the Hypocratic principle of <span class="elsevierStyleItalic">primun non nocere</span>—first and foremost, do not hurt—, as we must remember that iatrogeny was very frequent in medicine up to the 20<span class="elsevierStyleSup">th</span> century.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In accordance with the above, the medical profession was the first to self impose rules of conduct, summarized in the Hippocratic Oath and in other texts such as Maimonides’ prayer, regarded as the origin of the current Medical Deontology Code (MDC)<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> which, we might recall, comprises compulsory requirements for all active physicians regardless of the medical specialty, including those who work in the health administrations. Perusing the latest edition of the MDC (2011) is highly recommendable due to the exquisite wording of the rules that are meant to inspire and guide the professional actions of all physicians.</p><p id="par0020" class="elsevierStylePara elsevierViewall">However, the complexity of medical practice renders the MDC insufficient to resolve the ethical conflicts that arise during practice. In the last decades of the 20<span class="elsevierStyleSup">th</span> century the advent of bioethics extended the application of ethical values to all things related to health practice. The <span class="elsevierStyleItalic">Encyclopedia of Bioethics</span>, edited by Warren Reich in 1978, defines bioethics as <span class="elsevierStyleItalic">«the systematic study of human behavior in the domain of life sciences and healthcare, examining said behavior in the light of moral values and principles»</span>.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Bioethics establishes that all medical act, if carried out in the spirit of the search for excellence, should be technically correct and should also respect the ethical principles of autonomy, beneficence, non-maleficence and justice. Of these four principles of bioethics, the principle of justice is largely ignored even though it should be very present, above all in public health. For said four principles to be efficient, the virtue of honesty in health professionals should be present because there is the risk that these principles could become simply theoretical. We should assume the obligation of building a better ophthalmological science for future generations, and this involves not only improvements in diagnostics and treatments but also enhanced ethical behavior with our patients.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The following questions highlight the fact that ethical problems are very present in our profession:</p><p id="par0035" class="elsevierStylePara elsevierViewall">Concerning complicated diseases such as age-related macular degeneration (AMD) or glaucoma, for which there hardly is any primary prevention, is it legitimate to request genetic tests as they are becoming available? How can patients benefit from knowing that they will have said diseases? and, could this information even cause them damage?</p><p id="par0040" class="elsevierStylePara elsevierViewall">Additional questions include: to what point do we continue treating (in many cases with surgeries or invasive procedures) patients who have very few possibilities of success? And, when should we adopt what bioethics defines as the <span class="elsevierStyleItalic">Limitation of the therapeutic efforts</span>, in other words when do we stop so to avoid <span class="elsevierStyleItalic">therapeutic mercilessness</span>? Do patients receive the same consideration and respect in the public health as in private medicine? Are we indulging in <span class="elsevierStyleItalic">overdiagnosis</span> and <span class="elsevierStyleItalic">overtreatment</span>?<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">As regards relationships between colleagues and resident physicians, are they as respectful as they should be among peers? Does scientific fraud appear in the contents of scientific publications and/or the authorship thereof? Is the biohealth industry imposing care models in our specialty? What is the degree of legitimacy of clinic trials or frequent post-certification studies that on many occasions are designed (and in some cases analyzed) by the same biohealth industry? The answers to all these questions cannot be exclusively based on scientific knowledge as they also involve ethical issues.</p><p id="par0050" class="elsevierStylePara elsevierViewall">When a medical decision is difficult to make, it is discussed in clinic sessions to find the most appropriate solution. The same should occur when taking moral decisions. The method to be applied in the search of the best decisions is deliberation, and I believe that we should deliberate in the domain of medicine but we do not do this to resolve ethical conflicts. Moral conflicts produce uncertainty and we do not have the habit of deliberation, that consists in sharing reasons and arguments in order to find the best solution. Any deliberation session requires the ability to listen and to be willing to change our viewpoints or at least modify our ideas. We cannot expect clinic sessions or ethical conflict meetings to arrive at the perfect decision<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> but we can expect that the decisions taken at these sessions are honest, prudent and accountable, which are 3 ethical virtues of great importance. This can help us to take clinical decisions as well as to resolve ethical conflicts in our profession as well as in our lives. Let us keep this in mind.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Jiménez Benito J. Ética médica y oftalmología. Arch Soc Esp Oftalmol. 2017;92:99–100.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Breve historia de la ética médica" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A.R. Jonsen" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:4 [ "fecha" => "2011" "paginaInicial" => "20" "editorial" => "San Pablo Universidad Pontificia Comillas" "editorialLocalizacion" => "Madrid" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0040" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Inglish Pollock WB. Arabian Opthalmology [monografía en Internet]. 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