8.Doctor-societyrelationshipTopics:

Doctor-societyrelationship.Individual(patient)goodvs.publicgoodDoubleloyalty:individualvs.publicdutyJusticeinthemedicalpracticeandhealthcare,nondiscrimination.AllocationofscarceresourcesRightforhealthcare

GeorgeCristianCurca MD,Ph.D.Prof.demedicina legala si eticamedicala

Discipl.Medicina legala si Bioetica,FacultateaMedicina UMFCD

Individual(patient)goodvs.publicgood• Medicineisanhumanitarianprofession:itisaboutmakinggoodtoothers,

fightingwithdiseasesandhelpingpeoplerecoveringfromdiseasesorresearchingthescientifictruthwhichwillhelpotherscolleaguestohelpillpeople.

• Everypatientcomeswithneedformedicalcareandtrustthatthedoctorwillhelphim.

• Thedoctorowetothepatientadutyofcareissuedfromthemoraldutytotheentrustrelationshipwiththepatient.

• Thedoctorisempoweredtopracticewithbeneficence,non-maleficence,loyalty,justiceononesideandtorespectpatient’srightssuchastherightforlife,libertyandfreechoice.Autonomyisaguarantyofthepatient’slegalcompetenceandasourceforrespect

• Thedoctorprojectsthismoralflowofprinciplesnotonlytohispatientbutalsotothesociety(thirdparties)becauseheiscommittedtodogoodactions,toprotectanypersoninmedicalneed(extendedduty).

• Howevertheindividualgood,thepatient’sneedsprevailandthedoctormaynotsacrificehispatientorhismedicalneedsforthesakeofthepublicgoodorpublicmedicalneedsorscience.Hedoesnotfind,morallyandlegally,anysolidjustificationtosaveallotherswiththepriceofone’slifenomatterwhatatstake.

Doubleloyaltyasanextendedduty• Doctorshaveadouble loyaltytotheirpatients:thisloyaltyisnormallynotconflictualandissolvedby

doctor’swillingtobeloyalboth tothepatientandtothethirdparty,ortothepatientandsociety,ortothechildasapatientandtotheirparents,ortothemotherandtoherunbornchild,etc.Thisdoubleloyaltyisanextendeddutyofthedoctorandemergesoutsidedoctor-patient’srelationship,projectedtothirdpartiesorsocietyinitself.

• Howeverthisdouble loyaltymaycollapseintoconflict:thedoctormustsolvetheconflicttakingintoaccountthat“thehealthofmypatientismyfirstconsideration”.

• WMADeclarationofLisbonontheRightsofthePatient,1981“Wheneverlegislation,governmentactionoranyotheradministrationorinstitution DENIESPATIENTSTHESERIGHTS,PHYSICIANSshouldpursueappropriatemeansTOASSUREORTORESTOREthem”.[http://www.wma.net/en/30publications/10policies/H/index.html]

• WMAInternationalCodeofMedicalEthics,1949• “APHYSICIANSHALLactinthePATIENT'SBESTINTERESTwhenprovidingmedicalcare.APHYSICIAN

SHALLowehis/herpatientsCOMPLETELOYALTYandallthescientificresourcesavailabletohim/her”.[http://www.wma.net/en/30publications/10policies/c8/index.html]

• WMAStatementonHealthPromotion,1995Bali“MedicalpractitionersandtheirprofessionalassociationshaveanethicaldutyandprofessionalresponsibilityTOACTINTHEBESTINTERESTSOFTHEIRPATIENTSATALLTIMESandTOINTEGRATEthisresponsibilitywithabroaderconcernforandinvolvementinpromotingandassuringTHEHEALTHOFTHEPUBLIC.”http://www.wma.net/en/30publications/10policies/h7/

• Wheneverinaconflictofinterestanydoctorwillsolvetheconflictinfavorofthebest interestofthepatientandwillpromotethe interestsofthevulnerableperson(deontologicalview:Kantiansecondlaw).

• Sometimesthedoctormaybeaskedtoputthepublicinterestsoverhispatient’sinterest.Hewillstruggletodefeathisindependenceandtheprofessionalismofhisactivity.

• WMAStatementonHealthPromotion,1995Bali“InareasorjurisdictionsinwhichBASICPUBLICHEALTHSERVICESARENOTBEINGPROVIDEDADEQUATELY,medicalassociationsmustworkcollaborativelywithotherhealthagenciesandgroupstoestablishprioritiesforadvocacyandaction.Forexample,inacountryorareawithLIMITEDRESOURCESinwhichpotablewaterandsewagefacilitiesarenotavailabletomostresidents,THESEISSUESshouldbegivenPRIORITYovertheexpendingofresourcestoobtainaNEWMEDICALTECHNOLOGYthatwouldprovideSERVICETOONLYAFEWPEOPLEINTHEPOPULATION”.[http://www.wma.net/en/30publications/10policies/h7/]

• WMADeclarationofLisbonontheRightsofthePatient,Lison 1981• IncircumstanceswhereACHOICEMUSTBEMADEBETWEENPOTENTIAL

PATIENTSforaparticulartreatmentthatisinLIMITEDSUPPLY,allsuchpatientsareentitledtoaFAIRSELECTIONprocedureforthattreatment.ThatchoicemustbebasedonMEDICALCRITERIAandmadeWITHOUTDISCRIMINATION.

• [http://www.wma.net/en/30publications/10policies/l4/]

Nodiscrimination(justiceprinciple)

• WMADeclarationofGeneva,1948• “IWILLNOTPERMITconsiderationsofage,diseaseordisability,creed,ethnicorigin,gender,nationality,politicalaffiliation,race,sexualorientation,socialstandingoranyotherfactortointervenebetweenmydutyandmypatient”[http://www.wma.net/en/30publications/10policies/g1/]

Scarceresourcesallocation• Itdoesnotexistsamedicalsystemwithunlimitedresources.• Itisequitabletoestablishtheresourceallocationbeforethe

needscome.Contagion (2011)[http://www.imdb.com/title/tt1598778/?ref_=fn_al_tt_1]Soonafterherreturnfromabusiness triptoHongKong,BethEmhoff diesfromwhatisafluorsomeothertypeofinfection.Heryoungsondieslaterthesameday.Thusbegins thespreadofadeadlyinfection.HerhusbandMitchhoweverseemsimmune.FordoctorsandadministratorsattheU.S.CentersforDiseaseControl, severaldayspassbeforeanyonerealizestheextentorgravityofthisnewinfection.Asthecontagionspreadstomillionsofpeopleworldwide, societalorderbeginstobreakdownaspeoplegetinfected.Themovie talkabout resourceallocation,theindividualdutyvs.publicduty,patientdutyvs.publicduty,loyaltyanddevotion.

Models forallocation1. Themodelderivesfromthedutytothepatient(Hippocraticor

deontologicalmodel)

Rationale:1. Theduty toward thepatientis above theduty tosociety2. Thedoctor owe his patienthis firstthought,his firstactionand

patientinterests arehis firstconsideration.3. Individual rights prevails overpublicrights.4. Individual goodis prevalent.Ifnotso,societywould collapse

because any societyis based onindividual rights ofhis citizens.

2. Themodelderives from theextended duty tosociety(utilitarian)

Rationale:1. Thegroundbase forthis modelis theextended duty ofthe

doctor,beyond theduty owe tothepatient,therefore theduty topromote publicgood.

2. Thedoctor is still induty buthis duty is toward thesociety:his duty is toprovide asmuch goodaspossibleforasmany peopleaspossible.

3. Thedoctor returns tosocietywhat he received before:hisexperience andcompetence.

4. Every patientis anindirectpatientofthat doctor andthetotalgoodtoallpatientsprevail overthegoodtojust oneindividual (his directpatient).

5. Individual interest is sacrificed overtheinterest ofsociety.6. Socialgoodbenefices

3. Themodelunder economical influences

1. Inthismodeltheprofessionaldecisionandscarceresourceallocationaremadeoneconomicalgroundsandbyfarnotusingprofessionaldecisions.

2. Patientsreceivemedicalcareasaservice(theyareclients)andthemedicalstaffandthemedicalsystemareserviceproviders.

3. Medicineisasocialdomainofservicesanditsmainscopeistobringprofitstoall.

4. Asfarasthepatientishealthierthesystemiswealthier,becausethisisdotothefactthattheservicesarepermanent.

5. Asfarasthepatientsaresickerthesystemispoorerbecausethepatientsarechronicallyinamedicalcareneedrequiringcurativeserviceswhichcostsalotbringinghelp,alleviatingalways,amelioratingmostofthetimeandprovidingcuresometime:thesystemsdeliversserviceswithoutlong-timeresults,thereforebenefitsarelower.

Professional independence. “Thedoctorhasthedutytodefendhisprofessional independence, anydeterminationofthemedicalcareortohisprofessionaldecisiononeconomicaloradministrativegrounds isstrictlyforbidden”.

SOCIALNEEDALLOCATIONPRINCIPLES

1. Thedistributiveprincipleinsociety:societyhasadutytohisindividualsandtheseindividualshasalsoadutyonetoanother;the distributivejustice=sociallyjust distributionofgoodsinasociety:– Possibleapproaches:

1) oneindividualisentitledtoreceivegoodfromsocietyifpreviouslyhegavegoodtosociety.Howmuchgood?Howmuchonehaddelivered.

2) Givingmoretothatonewhobenefitsmore,andlesstothatonewhobenefitsless.3) “Youcantellthejusticeofasocietybyhowittreatsitsleastwell-offmembers”

(J.Rawles)

2. Thejustdistribution:equaltoequals3. Equitabledistribution:minimalstandardofhealthcare

Thephilosophicalprinciplesatthebaseofallocationprinciples:libertarian,utilitarian,egalitarian,restorative.

1. Equalitarianprinciple:Allhumansareequal(equaltreatment):lotteryprinciple,theprincipleofthefirstcome-firstserved.

2. Prioritarian principle(favoritism):tothatonewhichismorevulnerable,tothatonewhichismoreill,tothatonewhichismoreyounger,tothatonewhichhasagreatersocialcontribution(elderlypeopleorvulnerablemembersareusuallydiscriminatedonthisconcept)

3. Maximizingbenefitsprinciple(utilitarianism):cost-efficiencytosaveone’slife(morelifesavedthanlesslifesavedisbetter),prognosticandyearstolive;howefficient ismedicalcarebecomeveryimportant,morethanthedutyofcare.

4. Socialutilityandcontributionprinciple(distributiveprinciple):instrumentalvalueofindividualsandsocialreciprocity(society/individuals);contractbaseconcept(contractarianism:thesocialcontracttheory):everyindividualhasadutytohisfellowship,J.Rawls.

EqualitarianprincipleEqualtreatment

• Characteristics:– Allhumansareequal(equaltreatment);Non-discrimination

– Thelotteryprinciple,theprincipleofthefirstcome-firstserved.

– Firstcome-firstservedprinciplebringsequalityandopportunityforallbutfavorsrichpeople

– Equalaccesstomedicalcareandequalchancetoreceivescarceresources(i.e.organdonation)

Prioritarian principle(favoritism)Prioritizingmedicalscarceresource

• Fromthewell-offtothatonewhichismorevulnerable,moreill,moreyounger,orbroughtagreatersocialcontribution(elderlypeoplearediscriminatedusually:lesseagertofightfortheirbestinterests,lesscapabletofightfortheirbestinterests,moreeasilytobetakenoutoftheway,pronetosacrifice)

• Firsttothepoorer,firsttothemostvulnerable,firsttotheweakest:theruleofsalvationtakingintoconsiderationthat:– theresourceisscarceonatemporarybase– Thedoctorhasamedicalcareduty– Thecitizenwell-offbearsnochanceatall,thereforemedicalcareisa

beneficenceforhim(anyonemaybewell-offsometimeinhislife):asocietalrequesttosolidarity

• Limits:• Theallocationhasnotabiologicalgrounddecisionthereforethemedical

results(efficiency)maybepoor.• Thosewithhigherbiologicalchancesmaynevergetthecurethereforetheir

healthmaydeteriorateandfinallytheymaydiealso:thereisapossibilitythatallpatientsmightdiefinally.

• Orfirsttotheyounger:children,youngpeople(i.e.vaccinationprograms).Theolderpeoplegivethesacrifice(societyasks,individualaccept).

• Howtochoosebetweentheweakoneandthatonewithoutasupport?

• Prioritizationtakesfromthewell-offandfavoritismgivestotheworst-off

see“TheTheoryofJustice”,J.Rawls:"JusticeasFairness",andthetwoprinciplesofjustice: thelibertyprinciple and thedifferenceprinciple)[http://en.wikipedia.org/wiki/A_Theory_of_Justice])

Maximizingbenefits(utilitarianism)Medicalbenefitsforall(asmanyaspossible)

• Cost-efficiencytosaveone’slife(morelifesavedseemsbetterthanlesslifesaved),evaluationprognosticandgoodyearstolive;howefficientisthemedicalmaybecomeveryimportant.

• Scarceresourcetothatonewhobenefitsmore.Whoisthatone?Howcanwefoundhim?Searchingforthepeoplevalueinyeartoliveandthendriving thescarceresourcestothatonewhowilllivemoreyearstolivebecausethatonewillbenefitmore:anyonehasavalueinyeartolivewhichmaybeevaluated.

• Question: Howcanweevaluatethevalueof10yearstoliveofayoungdoctorwithahematologicaldiseasevs.10yearstoliveofa55yearsolddoctor withthesamedisease?Thesamewithanyotherpersonorprofession

• Exemple:– Let’sconsidertheyoungdoctor:hehasnotyetsomeone tocareaboutandnotyeta

professional career:ifcured,ihe willcometohismedicalofficeandprovidetreatmentandmedicalcareforasmuchas80.000patientsinhisentirecareer(40years):inthefirst10yearstocomehemaytreatandmaycure20.000persons, citizens.

– Let’sconsidertheolderdoctor:hehas2childreninhispersonalcareandhasalreadytreated60.000patients,still20.000totreatinhisprofessional lifespantillretirement.Whichonehasmorefulfilled 10yearstocomeandtoserve(forsocietycare)or10yearsofgreaterqualitytocome(forhimselfandsociety)?

• QUALY(quality-adjustedlife-years)includesameasureoftheprognosisinlive-years(i.e.slightreducedmobility=0.85yearsofperfecthealth)

• HoweveranappendicitiswelltreatedbringsmoreQUALYforlesspeople(thosewithappendicitis)thanthetreatmentofateethcavityforasmanyaspossible

• DALY(disability-adjustedlife-year).DALYincludesQALY(i.e.1yearofblindnessequals0.6yearsofperfecthealth).

• HoweverDALYdoesnottakeintoconsiderationinterpersonaldistributionandconsiderthat1yearoflifeofayoungpersonismorevaluablethan1yearofliveforanadult/olderperson

– Questionstoaskwhentryingtodeterminethequalityoflifeonasocialbaseground• Howdowemaydotheyearstolifecalculation?• Whatabouttheeducationalcostsinvolvedintheirtraining(ifalreadyabsorbed)?

• Whataboutexperience?Theyoungdoctormaypossiblecommitserrorsbecausehestartspracticingtheotheronehasalreadyadeterminedexperience(thereforetheyoungdoctormaynotactuallycure20.000citizens/10years)

• Whatabouttheintrinsicvalueashumans?Whatabouttheirvalueoflifeasindividuals? Isitdifferentbetweenthosetwodoctors?

• Instrumentalvalueofindividuallife:lifeanddignitybearsdifferentvalues?lifevaluedissociateandbecomesavaluemoreimportantthanthedignity(thismoraldissociation isthereforeanimmorality)

• Whichistheinstrumentalvalueofthetheyoungdoctorvs.theolderdoctor?• Orweactuallyhastogiveaqualitytotheirlifetakingintoaccountthepersonsdependingoneach(socialvaluelookeduponnotasaninstrumentalvaluebutasanutilitarianvalue)?

• Orthequalityoftheirlifeisjustbiologicallyscored?Ifsowhereandhowisscoredtheirconscience,rationality,autonomy,personalvalues,theirplacebetweentheirown,theirplace insociety,theirvaluerankedbytheircommunity,etc.?Howisthenscoredtheirsocialutility?

• Distributionbasedonprognosisvs.thenumberofsavedlives.Itismoreequitabletospreadresourcestothosewhichhasabetterchancetobecuredbasedonmedicalprognosis:someonereallymaygotthechancetobesavedfinally.

• Savinglivestakingintoconsiderationprognosismeansactuallysavingasmanylivesaspossiblebecauseonlythoselivesthatmaybesavedwillbesavedandthismaximizestheoutcome.

• Medicalcriteriasuchaswhatmaybecure,availabletreatment,prognosis,pathologicalstate,emergencystate,perilforlife,justificationofthetreatment,opportunity,risks,benefitshastobetakenintoaccountwhenmakingmedicaldecisions.Thedoctorhastopromote“Thehealthofmypatientismyfirstconsideration”GeneveDecl),thedoubleloyaltybutalwaysgivingsupportforindividualvalues(patient’svalues,hisownvalues)whichovercomesocietyneedsandsciencebenefits

• Toofferarealextrachancetothatonewhichishealthiervs.thatonewhichissicker(vulnerable)ishoweverunethicalbecauseleavethesickerwithoutanychanceandsupportthehealthiertobeevenmorehealthyandthatisbeyondthescopeofmedicineandmedicalcare(dutytohealthcare,healthofMYpatient,tocureandtopreventthesickness)

• Togivemoreyearstocometothehealthier(sohewillliveevenlonger)isfoundunethicalvs.togiveyearstocometothelesshealthy(whichwillliveevenlesseriftheresourceswillbeallocatetothehealthier):thustakingyearsfromoneindividualandgivingyearstootherindividualisfoundunethical.Inasmuchasleavingthevulnerableinneedformedicalcarewithoutanychanceofgettingwell.Orinthesamemannertocreateaprejudicetooneindividual(sacrifice)inordertohelpanotherone(evenmorethanjustone)becausenohumanbeingismorevaluable,allhumansarebornequal,allhumanshasaninvaluableintrinsecvalue.

• Question:Ifyouareinpracticeandyouadministrateonlyscarceresourcesandyouhavethepossibilitytobringonlyfewyearstocomejustforone(i.e.becauseofhiscomplexdisease–i.e.apatientonarespiratorysystem)butalotofyearstocomeformore(i.e.becauseoftheirneedtoreceivepreventivemedicalcare–i.e.dialysesorteeht cavitytreatment,etc.)whatwouldbeyourchoice?Actuallyyouarethephysicianorthemanager/administratorofthemedicalsystem?Isitadifferenceinethicsanddeontology?Whatisdifference?Whatisyourdutyasadoctor,asaproffesional?

Promotingthesocialvalue

• Instrumentalvalueoftheperson.Thisprincipleprioritizeparticularindividualsfortheirskillsorsocialvalue(i.e.avalueusefulfortheothersinordertosurvive,etc.).

• Reciprocity.Thisprincipleprioritizethedutythatthesocietyhastowardthoseindividualsthathasasocialvalueandhavepaytheirdutytowardsocietyandareinaneedforthecure(allocationprincipleorreparatory/rectificativejustice)

MEDICALNEEDALOCATIONPRINCIPLE

• WMARightofthepatientDeclaration,Lisbon,1981• “Incircumstanceswhereachoicemustbemadebetweenpotentialpatientsforaparticulartreatmentthatisinlimitedsupply,allsuchpatientsareentitledtoafairselectionprocedureforthattreatment.Thatchoicemustbebasedonmedicalcriteriaandmadewithoutdiscrimination.”

?1. Inahospitalexists100patientswithacertainlethaldisease.

Onemedicinecapsuleisenoughtocurethedisease.Yougot50capsules:howdoyouintendtousethem?

2. Inahospitalexists100patientswithacertainlethaldisease.Twomedicinecapsuleareenoughtocurethedisease.Yougot100capsules:howdoyouintendtousethem?

3. Inahospitalexists100patientswithacertainlethaldisease.50patientsneedjustonemedicinecapsuletobecuredand50need2capsules.Yougot50capsules.Howdoyouintendtousethem?

4. Inanyofthesecircumstancesiscorrecttokeeponecuredoseforyourself?Mayyouconsiderthatthisoptionisawiseoptionrichinpublicgoodbecauseifthedoctorissavedmanyothermaybesaved.IsitOKtothinklikethis?

Allocationsystemsofscarceresourcesinorgantransplantation

• IntheUSA,isusedtheUNOSsystem(unitedsystemfororgansharing).

• Thesystemcombines3principles(2inconsistentand1consistent)a) Firsttothatonewhichismoresick/sickernow(biologicalground

decision)b) Firstcome-firstserved(waitingtime)c) Prognosis(HLA,etc.)

• Dependingontheorgantobetransplantedthe3abovementionedprinciplesweightdifferent:

• Kidneyandpancres:b)• Heart:a)• Lung:b),a),c)

PUBLICHEALTH,THERIGHTTOMEDICALCARE

• Ishealthcareafundamentalright?• Ishealthcarearight?

WorldMedicalAssociation(WMA)- DeclarationontheRightsofthePatient

34thWorldMedicalAssembly, Lisbon,Portugal, Sept/Oct1981;amendedbythe47thWMAGeneralAssembly, Bali,Indonesia, September1995,revisedinOct.2005,Chile

PREAMBLETherelationshipbetweenphysicians,theirpatientsand broadersocietyhasundergonesignificantchangesinrecenttimes.Whileaphysicianshouldalwaysactaccordingtohis/herconscience,andalwaysinthebestinterestsofthepatient,equaleffortmustbemadetoguaranteepatientautonomyandjustice.ThefollowingDeclarationrepresentssomeoftheprincipalrightsofthepatientthatthemedicalprofessionendorsesandpromotes.

Physiciansandotherpersonsorbodiesinvolvedintheprovisionofhealthcarehaveajointresponsibilitytorecognizeandupholdtheserights.Wheneverlegislation,governmentactionoranyotheradministrationorinstitutiondeniespatientstheserights,physiciansshouldpursueappropriatemeanstoassureortorestorethem.

Righttomedicalcareofagoodquality

a.Everyperson isentitledwithoutdiscrimination toappropriatemedicalcare.b.Everypatienthastherighttobecaredforbyaphysicianwhomhe/sheknowstobefreetomakeclinicalandethicaljudgements withoutanyoutsideinterference.c.Thepatientshallalwaysbetreatedinaccordancewithhis/herbestinterests.Thetreatmentappliedshallbeinaccordancewithgenerallyapprovedmedicalprinciples.d.Qualityassuranceshouldalwaysbeapartofhealthcare.Physicians,inparticular, shouldacceptresponsibility forbeingguardiansof thequalityofmedicalservices.e.Incircumstanceswhereachoicemustbemadebetweenpotentialpatientsforaparticulartreatmentthatisinlimitedsupply,allsuch patientsareentitled toafairselectionprocedure forthattreatment.Thatchoicemustbebasedonmedicalcriteriaandmadewithoutdiscrimination.f.Thepatienthastherighttocontinuityofhealthcare.Thephysicianhasanobligation tocooperateinthecoordination ofmedicallyindicatedcarewithotherhealthcareproviders treatingthepatient.Thephysicianmaynotdiscontinue treatmentofapatientaslongasfurther treatmentismedicallyindicated,withoutgiving thepatientreasonableassistanceandsufficientopportunity tomakealternativearrangementsforcare.

• UNIVERSALDECLARATIONONBIOETHICSANDHUMANRIGHTS,UNESCO,2005http://portal.unesco.org/en/ev.php-

URL_ID=31058&URL_DO=DO_TOPIC&URL_SECTION=201.html• Art.14,al.22.Takingintoaccountthattheenjoymentofthehighestattainablestandardof

healthisoneofthefundamental rightsofeveryhumanbeingwithoutdistinctionofrace,religion, politicalbelief,economicorsocialcondition, progress inscienceandtechnologyshouldadvance:(a)accesstoqualityhealthcareandessentialmedicines,especiallyforthehealthofwomenandchildren,becausehealthisessentialtolifeitselfandmustbeconsideredtobeasocialandhumangood;(b)accesstoadequatenutritionandwater;(c)improvementoflivingconditionsandtheenvironment;

• CHARTEROFFUNDAMENTALRIGHTSOFTHEEUROPEANUNION (2010/C83/02)http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:C:2010:083:0389:0403:en:PDF• Article35Healthcare.Everyonehastherightofaccesstopreventivehealthcareandthe

righttobenefitfrommedicaltreatmentundertheconditionsestablishedbynationallawsandpractices.Ahigh levelofhumanhealthprotectionshallbeensuredinthedefinitionandimplementationofalltheUnion'spoliciesandactivities.

• Article36Accesstoservicesofgeneraleconomic interest.TheUnionrecognises andrespectsaccesstoservicesofgeneraleconomicinterestasprovided forinnationallawsandpractices,inaccordancewiththeTreaties,inordertopromote thesocialandterritorialcohesionoftheUnion.

• CONSTITUTIONOFTHEWORLDHEALTHORGANIZATION,TheConstitutionwasadoptedbytheInternationalHealthConferenceheldinNewYorkfrom19June

• to22July1946,signedon22July1946bytherepresentativesof61States(Off.Rec.WldHlth Org.,2,100),andenteredintoforceon7April1948.

• AmendmentsadoptedbytheTwenty-sixth,Twenty-ninth,Thirty-ninthandFifty-firstWorldHealthAssemblies(resolutionsWHA26.37,WHA29.38,WHA39.6and

• WHA51.23)cameintoforceon3February1977,20January1984,11July1994and15September2005

• http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf

• “Healthisastateofcompletephysical,mentalandsocialwell-beingandnotmerelytheabsenceofdiseaseorinfirmity.

• Theenjoyment ofthehighestattainablestandardofhealthisoneofthefundamentalrightsofeveryhumanbeing withoutdistinctionofrace,religion,politicalbelief,economicorsocialcondition.

• Thehealthofallpeoples isfundamental totheattainmentofpeaceandsecurityandisdependentupon thefullestco-operationof individualsandStates.

• TheachievementofanyStateinthepromotion andprotectionofhealthisofvaluetoall.”

• CONSTITUTIONOFROMANIA• Art.34.“Therighttomedicalcare,al.1“Therighttomedicalcareisguaranteed”.

• Mr.BU,85yearsold,hasAlzheimerfor10yearsandisinanadvancedstage.Hisclinicalstateisprofounddeteriorateinthelatetime.Hecannotcontrolhismouthmovements:hereceivedanasalgastrictubebutheremovesitrepeteadly.Asurgicaltubeisreccomended.

• Hisfamilyisformedbyonedaughterwhodedicatedhislast10yearstothehealthcareofhisfather,theeldersonwhichsupportedeconomicallythemedicalcareofhisfatherandother3brotherswhichhasnotbeeninvolvedintheirfatherhealthcaretillnow.

• Thedaughterasksthedoctortoperformwhatevernecessaryfortheirfathertoliveon.

• Theeldersonasksthedoctortogiveuptothetreatementandlettheirfatherdodiewithdignitybystopingthefood.

• The3brothersconsiderthattheyarenotentitledtomakeamoralchoicebecausetheyhavenotbeeninvolvedtillnowintheordeilofthemedicalcare.

• Whathavethedoctortodo?