In 1964 the World Medical Association adopted, in Helsinki, a Declaration regarding the Ethical Principles for Medical Research Involving Human Subjects. As we approach the fiftieth anniversary of the Declaration of Helsinki we should pause to reflect on how the world and medicine have changed, and examine our current needs and challenges.
As civilizations evolve and mature the epidemiology of disease changes. New morbidity patterns have evolved, especially in Europe, North America and Australia in the last 50 years. Whereas infectious diseases and traumatic disorders predominated in the past, chronic and degenerative processes are more common today. Cancer is taking its prominent place in the spectrum of chronic diseases. The numbers of doctors and medical staffs have grown significantly, but significant specialization has also taken place. We still take medical histories and examine patients, but rely more and more on modern medical technology to arrive at diagnoses.
To an increasing degree in modern times, medical philosophy focuses on topics of life and death, such as the management of patients who have cardiac arrests. In these instances, cardiopulmonary resuscitation is provided not only by medical personnel, but also by non-professionals who have obtained training in vocational schools.
In solving the dilemma of whether or not to begin resuscitation in a life-threatening emergency, the doctor should focus on the expected outcome – what will be the quality of life for the patient upon discharge from the hospital? Using modern medical expertise it is usually possible to return patients to fully functional lives and normal life expectancy following cardiac insult.
Cardiopulmonary resuscitation of cardiac arrest is successful in 70-98 per cent of attempts. After successful resuscitation, quality of life is ensured for most survivors, and it is very common for people to have long life expectancy in spite of serious cardiac disease.
An ethical dilemma arises when one has to allocate limited financial resources for health care in the 21st century: how much should be expended to prolong the life of one person versus spending the scarce health care dollar on a larger portion of the population? Since 1990 the average lifespan has been extended by one year every four years. During this same time period health care expenditure has increased three to five per cent a year, a figure much higher than the growth of the gross national product.
Today, given enough resources, people’s lives can be significantly prolonged with the aid of modern medicine. Doctors, patients and their families understand this. These resources are expended especially on prevention, early diagnosis and rehabilitation.
There is competition for the health care dollar. A certain portion usually comes from social security funds that have been paid for by individuals during their lifetimes to which they are entitled. The remainder is typically paid for by the state, to which people also believe they are entitled.
Regardless of the economic wealth of any country, resources are not unlimited. As a result, dissatisfaction with the health care system develops among medical professionals and the general public. In reality, the delivery of medical care in the 21st century has become a paradox: the more money that is expended on health care, the longer people live (although suffering from their chronic illnesses), but the more financial resources are needed.
Leaders of medical associations and other influential health officials around the world are paying increasing attention to health issues, such as disease prevention, smoking, alcohol, vaccination, nutritious food, physical exercise, ecology and a healthy lifestyle. And, a cornucopia of ethical problems has opened – public health issues exist in Europe and Africa, North and South America, Christian and Muslim countries. Implementation of public health improvements has often been met with a hypocritical attitude toward issues such as the calamity of smoking and the widespread use of narcotics. More than three million newborns die each year, mostly in developing countries. Lack of food in poor countries leaves 170 million children underweight, while at the same time, nearly a billion people in the world are overweight due to excess food consumption and lack of exercise.
In studying the social determinants of health, the World Health Organization has focused on nine broad areas: early child development, globalization, health systems, measurement and evidence, urbanization, employment conditions, social exclusion, priority public health conditions and women and gender equity. A dominant figure in the study of inequalities of health care and their causes is England’s Sir Michael Marmot. He maintains that social standing is an important determinant of health and life expectancy.
Recognizing the far-reaching changes that have occurred in medicine in the 21st century, it is obvious that a new document that addresses the ethics and philosophy of our modern time is in order. There is no organization better suited to produce this Declaration than the World Medical Association.