Comparative Assessment and Analysis of Medical Ethics and Experiences; A Code of Silence
I am Not Leaving and I am Not Staying
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Dr. Ebtisam Elghblawi (MBBCh, MSc, PG Dip)

Correspondence:
Email: ebtisamya@yahoo.com

INTRODUCTION

Ethics history
Medical ethics was first founded in academia in the 19 century, and was refined and revised to be a distinct role and duty of doctors and nurses towards their patients. And since that time medical ethics was introduced and considered to be an obligatory module in medical studies. Its main concern is about doctor patient relationships in terms of confidentiality and consent. It also extended to include the concept of Principalism which is applicable widely in the western countries, and that which would emphasise the right and the best course of action required (Sirkku K. Hellsten, 2008).
Ibnosina is the doctor of all doctors, and he defined medicine as the science by which we learn the various states of the human body when in health, and when not in health and the means by which heath is likely to be lost and when not lost, is likely to be restored. He is known as Avicenna in the west. He was extraordinary as he was a scientist, philosopher and physician. He was the foundation of codes of laws of medicine. His doctrines are still taught at many international universities such as Texas, Los Angeles, and Yale University, and many others. He believed that the human body can't be restored to health unless the causes can be defined. Ibnosina was the first to follow the ethical principles in his profession, and was well known globally (E.H.Aburawi, 2007). His secrecy to success was to combine religion, philosophy and medicine.
Ethics had been known for a long time, and the first document dealing with medical ethics goes back in time to Egyptian Papyri (16 century BC), where and when the doctor follows the rules, and is not guilty, should the patient die. If the doctor breaks the rules and the patient dies, so the doctor shall pay his life for that incident. Hammurabi set fees according to patient status in that time, and codes were laid out for physicians and surgeons, and followed precisely.

Development of codes of medical ethics
There are many activities which are under the cover of the medical umbrella. Abandon those activities, which are difficult to reconcile with medical ethics. There should be an avoidance of those medical activities which are undertaken and conducted by non licensed personnel; such as physician assistants, paramedics, physical therapists, pharmacists, physicists, nurses and technicians. That's why there should be a differentiation, namely primarily physician-centred, health care ethics including nurses, and other healthcare providers; clinical ethics which focus on hospital case decisions and aid diverse committees and consultations', and lastly bioethics including general issue of reproduction, fair distribution of organs (organ donations), other scarce life-saving resources, and protection of the biosphere (saving the planet).
This includes many issues which are the source of many debates, and discussion, such as when the doctor should act and take the decision instead of the patient, without consenting for his/ her best interest when applied and urgently needed (physician's paternalistic deception, and violation of patient confidentiality). When the patient has the right to refuse treatment or request assistance in dying, drug experiments, removing vital organs from dying brain stem patients (Choi EK, Fredland V, Zachodni C, Lammers JE, Bledsoe P, Helft PR., 2008), incompetent patients, foetal testing, IVF, genetic engineering, cloning, abortion, and conflicts of interest. This all created a state of meta-ethical questions about the role of professional codes, taking into consideration the religious concepts, ethical theories, committee consensus, moral intuition, clinical experience, and decision of clinical cases. The duty of a doctor can be divided into four main groups; duties toward patients, institutions, community, and meta-ethical issues. Firstly, from the ancient days, medical oaths described a doctor's duties clearly that they should be devoted to their patients bearing in mind their required character, and motives. Doctors should respond to their patient with complete passion and sympathy within the limits of their curative powers, and the harm incurred. Also sometimes patient wishes and treatment choice should be complied with after careful explanation (neo-paternalists). So to conclude this would mean that proper procedure should be important in medical ethics. Secondly; all these shifts indicate changes in medical practice from home, office, hospital, clinics, and lastly religious backgrounds. So, any decision is delegated by the bioethics committees because it involves many parties, such as nurses, lawyers, non physicians, social workers, chaplains, philosophers, citizen surrogates, patient advocates. The decision taken should be articulate and defensible. Thirdly, this would include restraint in matters of drug prescriptions, elective surgery, in-patient hospital stay, out-patient service. This would raise the issue of physician political and social responsibilities. Because there is a narrow concept for report of communicable diseases, gunshot wounds, signs of child abuse, serious violent intentions. The physician will deal with poor or rich patients, insured and non-insured patients (Hurst SA, 2009). This means reforming and redefining a social contract between doctors and society to educate and license. To sum up, this becomes less iatrocentric expanding to a larger field of health care ethics and clinical ethics. Lastly medical centres are a primary environment for medical ethics as well as medical care. It is where physicians and ethicists are based in medical schools, and their basic audience is medical students. The central concerns of ethics are response to need, dependency, and trust. Medical ethicists are different as they give weight to institutional interests and physician practice, while Bioethicists' concern with creating, saving, or taking life with or without physicians assistance, and this is a major discrepancy of morals.
The concept of brain death was first defined decades ago, and it still presents medical, ethical, and legal dilemmas, despite its widespread acceptance in clinical practice and in law (Choi EK, Fredland V, Zachodni C, Lammers JE, Bledsoe P, Helft PR, 2008).

International ethical codes
There are two main international well-known ethical codes for human experimentation. The Tokyo revision of the declaration of Helsinki of the world medical association (1975), and the proposed international guidelines for biomedical research involving human subjects of the council for international organizations of medical science and the World Health Organization (1982). The former was first adopted in 1964 by the world medical association, and it implies taking into first consideration the health of the patient and nothing else in human experimentation, and emphasised that any physician shall act only in the patient's best interest while supplying medical care which might weaken the physical and mental condition of the patient (Robert V. Carlson, Kenneth M. Boyd & David J. Webb, 2007). The latter must advance diagnostic, therapeutic and prophylactic procedures and the understanding of the aetiology and pathogenesis of disease. In 1949 an international code of medical ethics of the world medical association was adopted in London.

General assembly
Dated back to 13 December 1976, the WHO was invited to construct codes of medical ethics for imprisonment against torture, degradation, inhumanity, and other cruelness. Ethics generally speaking is based solely on moral, philosophic and religious principles of the society in which they are practiced; it can vary from one culture to another (Rispler-Chaim V, 1989). So what sounds legal is not necessarily ethical. A least a level of cultural consciousness is an obligatory requirement for the delivery of care that is culturally sensitive (Gatrad AR, Sheikh A., 2001).

How health should be defined
In 1948 the United Nations ratified the creation of WHO (World Health Organization). After which WHO had set up some fundamental bases of attainment by all peoples of the highest possible level of health.
Health is defined as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (Alejandro R Jadad, 2008).
Health is like beauty; it is in the eye of the beholder, and can't be captured. We need to frame the concept of health through services provided to the community, society, and modulate hopes and expectations accordingly with the limited available resources (Alejandro R Jadad, 2008).

Ethics in medicine: the four principles plus scope

An approach developed in the USA by Beauchamp and Childress, is based on four main basic prima facie moral commitments. The word prima facie is a term invented by the English philosopher W D Ross, and it does mean binding unless it conflicts with another moral principle. In that case we have to choose between them. This involves respect of patient autonomy. This is not a matter of attitude, but a way of acting to respect the autonomous act of the patient. Some patients have some religious beliefs (Orr RD, Genesen LB, 1997), and therefore we should not laugh at these or take them for granted. So patients should be informed and we should act accordingly to patient wishes and desires. This is called a prima facie sense.
There are four principles in medical ethics, and moral acts; namely beneficence, non-maleficence, respect of autonomy, and justice, all of which mandate its application when needed in the medical work field. We should have no difficulty in committing ourselves to these four prima facie moral principles (R Gillon, 1994). We should always consider those four principles before giving an answer. Previously Belmont reported three principles in the biomedical research and by this he considered beneficence and non-maleficence together and group them as one entity. Jonsen on the other hand explained that the word principle derived from primum (first) and capere (to take), so this would involve firstly a place in discourse and rules of thinking processes, permitting discussion around itself. To apply solutions, it required an understanding of the basis of principles, and then to apply them on purpose. So principles alone won't lead to ethical solutions, and hence decisions without doctrines are ethically empty.

Respect of autonomy; is the moral obligation to respect the autonomy of others in so far as such respect is compatible with equal respect for the autonomy of all potentially affected, that is expressed by Dr Gillon in his introductory remark. It is self rule of our thoughts, will, intention and action (R Gillon, 1994, Walker RL, 2008). Kantain terms stated as treating others as ends in themselves and not merely as means, keeping promises is another way of respecting peoples autonomy where it involves running someone's life which relies on that promise, because if not then it's a betrayal of trust (Pitak-Arnnop P, Schouman T, Bertrand JC, Hervé C, 2008). Autonomy is a general indicator of health, therefore it can be considered as a gauge parameter for self health care. Also, when relatives request you not to reveal the fatal truth to the patient who demands the real information. It is also, obligation to keep people's secrets. Also autonomy means not deceiving; also good listening to the patient and good communication is autonomy. So it requires us to obtain patient agreement before we do anything to them. In some cases it can be a complex situation if it is related to some genetic disorders, forexample, a conflict may come up when doctors know that information has implications not only for patients but also for family members but their duty of confidentiality prevents them from disclosing it (Walker RL., 2008). So in this case, two factors can be interacted, in other words a liberal perception of patient autonomy and an overriding practical principle of prevention of harm. So a doctor's legal duty of confidentiality should be reconsidered again when it concerns the family (Beran RG, 2008). Because, after all individual members are integral to the actual patient identity (Gilbar R., 2007, Hoop JG, 2008). It has been presumed that doctors know what is best for their patients, and therefore they can decide for them (paternalistic) because patients are the weak, more vulnerable party in the doctor-patient relationship, and by that medical ethics remain one-sided medical ethics duties (Heather Draper & Tom Sorell, 2002).

Beneficence and non-maleficence; is whatever you offer to a particular patient and not for patients in general to benefit rather than harm them. It is an act for the best interest of a patient without harming them. The traditional Hippocratic moral obligation of medicine stated providing utmost medical benefit to patients with minimal harm. In other words, the Hippocratic injection maxim: strive to help, but above all, do no harm, is the ruling maxim in medical ethics. This would need a vigorous and effective education and training before and during our professional practice and lives (R Gillon , 1994, van Teijlingen ER, Douglas F, Torrance N, 2008, Chertoff J, Pisano E, Gert B., 2009). For example, mastectomy can be a benefit for one woman, and a destruction of feminine identity for another (R Gillon, 1994). So it is the concept of making patients aware of the risks and benefits, and that at least benefits outweigh risks. For instance leaving a patient without treatment could have grave outcomes, so risky treatment should be applied and can be justified in that condition. So in this case non-maleficence is not absolute and must be balanced against beneficence. In some countries euthanasia is accepted as standard medical practice where a medical expert can't offer any further help, and this is applied in order to alleviate patient suffering and misery from incurable aliments. So an argument may ask if euthanasia (mercy killing) is good medical practice or murder. It's morally required when a patient requires it for his/her best interest and it is a respect of his/her autonomy as well as to ease his/her suffering in certain incurable conditions. So is death for the patients benefit? It is still a contradiction though. Killing in itself is a wrong so is whether to allow death to come of its own accord, or mercy killing. So we can't predict what the outcome of some terminal illness is in true life. Noteworthy non-maleficence is cultural and religious and issues can vary accordingly.

Justice; is defined as fair distribution of resources which constitute the heart of any justice, and respect of people's rights and respect for morally acceptable laws (Prudil L., 2008, Buijsen M, 2008). This simply denotes that we physicians should deal with every patient irrespective of some measures; such as socio-economic status (Hurst SA, 2009), refusing to treat patients with chronic bronchitis who smoke, or those who have alcoholic cirrhosis, refusing to give a sickness certificate when a patient can't work, notification of an infectious disease and so privacy of patient is breached (McCarthy RL, 2008). If such are unethical and unacceptable, we don't need to be judgmental, we just need to apply what we have in hand to help the patient out of their misery if possible. Also prescribing an expensive drug or investigation when cheaper ones are available and can help is another unethical issue. We should weigh out all our behaviours and analyse them within the four mentioned principles. The principles of justice, beneficence, and non-maleficence are prescriptions of the Hippocratic Oath.
Those four principles were well known through the Holy Quran and among the sayings of the prophet Mohammed, however with some slight differences of hierarchy between the western and Islamic school of thoughts. As for example, western society gives more stress and priority to autonomy, and Islamic society gives justice the priority (Kiarash A, 2008).
In certain situations and cases, decisions should be taken carefully and should be distinguishable whether as a physician or an organisation, a profession or society makes that decision, for example when to respond to patients' wishes for an abortion, considering hospital policy, society values, religion and law prospectively, hysterectomy in handicapped patients, mentally handicapped young children, ignoring those individuals who are HIV infected, and mercy killing for those in deep pain or incurable coma or illness. In such cases the prima facie should be respected unless there is a good moral reason not to do so. This can be called empowerment, and this has gained popularity recently, as it combines both respect of autonomy and beneficence, because it acts by doing things to help patient to be more in control of their health (R Gillon, 1994).

Islam is governed and guided by Sharia (jurisprudence) which is based solely on the Holy Quran, and Sunna and Hadith (Prophet Mohammed sayings), and opinion of Scholars (Aimma), (Athar S., 2008). Islam after all permits flexibility, adaptation to the necessities of life, and any shifts in ethics rely on the current culture where applied (Rispler-Chaim V, 1989, Gatrad AR, Sheikh A, 2001).
God has ordered us to look for knowledge and compose discoveries to improve our lives and our surroundings. Its not only that, we should emphasise the importance of Islamic code of medical ethics and thought in the medical curriculum (Al-Umran KU, Al-Shaikh BA, Al-Awary BH, Al-Rubaish AM, Al-Muhanna FA., 2006).
The basic deficiency of the developing countries is that medical ethics do not form a main part of mainstream thinking or that within the medical profession.

Moral foundations
There are many topics where morals and ethics are involved and need a decision of another party to take it forward. These include abortion, ethical issues in pregnancy, female circumcision, timing of childbirth, organ donations and transplantation, stem cell research (Larijani B, Zahedi F, 2008, Iltis AS, Rie MA, Wall A, 2008), cosmetic surgery, treating infertility (in-vitro fertilisation), female and male sterilization, hymenoplasty, cloning, blood transfusion before the era of HIV, narcotics in terminally ill patients, cosmetic surgery, doctor-patient relations, aging group care, geriatrics, psychotherapy, paediatrics problem, medical education and publication, health care for geriatrics with or without dementia, brain stem death, coma, death, the do-not-resuscitate (DNR), and the dying patient and euthanasia, genetic manipulation and engineering, animal experimentation, sex selections, spiritual counselling, removing endo-tracheal tubes in patient with brain stem death (Cosyns M, Deveugele M, Abbadie B, Roland M., 2008), medicines containing alcohol, also ethical issues in immunisation (Isaacs D, Kilham H, Leask J, Tobin B., 2009), and care of cancer patients. All of these create a complicated dispute between the Islamic and non Islamic worlds (Jonathan E. Brockopp, 2008).
The subject of brain death was defined decades ago, and it had a significant impact on the procurement of organs from cadavers. It still presents a major subject of debate for bioscientists, legal experts and religious scholars, as well as for the general public (Akrami SM, Osati Z, Zahedi F, Raza M., 2004).
Islam holds life as sacred and belonging to God and all creatures would die one day, as death is a transition stage between two different lives. Issues like, DNR (Do Not Resuscitate) is acceptable (Sarhill N, LeGrand S, Islambouli R, Davis MP, Walsh D., 2001, Huddle TS, Schwartz MA, Bailey FA, Bos MA, 2008). As well as that of assisted reproduction in Islamic world is accepted (ART, assisted reproductive technology) for couples with infertility of moderate means (Eisenberg VH, Schenker JG, 1997, Serour GI, Dickens BM., 2001).
Another issue, female circumcision was performed long ago by untrained persons, or a local village practitioner for religious and historical beliefs. Nowadays this is unacceptable religiously or medically as it causes violation of human rights and female genital mutilation. This can be banned by education and by imposing legislation (Abu Daia JM., 2000). Female and Male sterilization dates back to the time of Hippocrates for preventing hereditary mental diseases. The first female surgical sterilization was done in 1823 by James Blundell. And the first surgical vasectomy was done in the 19th century in the USA (Rizvi SA, Naqvi SA, Hussain Z, 1995). In that period male vasectomy was considered genocide during Nazi rule in Germany. Sporadically Islam, Christianity, and Judaism references explicitly prohibit contraception. Informed consent is needed for such operations. In the USA it is legal, however in some other countries it is not, and in Africa it is illegal to regulate fertility. It is the will of the couple as to how many children they want and when to stop. Family planning services should be part of any national health care system including the voluntary contraception services (Rizvi SA, Naqvi SA, Hussain Z., 1995).
Ageing population is increasing the prevalence of chronic incurable diseases, which are associated with deaths worldwide and this needs our attention and care especially in the developing countries where it's still missing.
Re-virgination may have fastidious meaning to women considering marriage in cultures where a high value is placed on virginity to restore the condition of female genitals. It can be defined either to be restoration or mutilation. However such females who reach an age of consent, and request such operations, but considering Islamic values and cultural issues, medical and human rights abuses that would make for another opinion and prohibition (O'Connor M, 2008).

A series of papers on organ donations have recently disputed whether non-heart beating organ donors are alive and whether non-heart beating organ donations breach the dead donor rule (Iltis AS, Rie MA, Wall A., 2008). In fact physicians think patients to be dead or not according to physician intention to resuscitate or not. Thus, non-heart beating donors may be declared dead without meeting the criterion of strong irreversibility even though strong irreversibility is implied by the concept of death. Such judgment is learned by physicians as they learn the practice of medicine and may vary according to circumstances. From that concept physicians can be trusted to determine the eligibility for organ donation for the patient interest and not for increasing the availability of organs (Huddle TS, Schwartz MA, Bailey FA, Bos MA., 2008).
Also a double effect would be taking into consideration when a doctor prescribes morphine to a terminally ill patient, where it alleviates pain and hastens demise of a patient by suppressing respiration.

Stem cell research and cloning ethically created a lot of concern as to whether it is acceptable in Islam or not, bearing in mind the benefits. In Islam acquirement of knowledge is a form of worship, but it should be confined within God's will and laws, because after all there should be a balance between God's creation and any new discovery, or invention whereby egotism can be a big conflict. Any research should follow Islamic ethical basics set forth in the Quran and Sunnah (Fatima Agha Al-Hayani, 2008).

Genetics further intimidates conventional core conceptions and standards, such as those of consent and confidentiality; as it reveals certain information such as identity, and consanguinous relations, which is out of kilter with traditional medical ethics, by human genetic mapping, and disclosing the blue print of a human being (genetic manipulation), (Sirkku K. Hellsten, 2008).

So, any moral goodness and badness can be ruled out by reason on its own, therefore any judgment and decision should involve a broader observation of new definitions and justice established by a valid reason (Kiarash A, 2008).

Immunisation programmes raise concerns about ethical issues as well. Issues are whether to enforce immunisation and how to deal with those parents who fail to comply with that, bearing in mind that those put their children in danger of contracting severe illness (vaccine-preventable diseases), and an access to vaccination programmes and hazards associated with vaccination in terms of vaccine efficacy and safety and credibility (vaccine-related injury) (Isaacs D, Kilham H, Leask J, Tobin B., 2009).

Informed consent: luck or law
The Council for International Organizations of Medical Sciences (CIOMS) suggested the most accepted the well known definition of informed consent, as "a decision to participate in research made by a competent individual who has received the necessary information; has adequately understood the information; and after considering the information, has arrived at a decision without having been subjected to coercion, undue influence, inducement or intimidation". So the doctors should ensure a good understanding of the patient before consenting, and that is called capacity to consent after full disclosure of information (18 years and above, physically and mentally accountable). There must be evidence of choice with a reasonable outcome firstly, and this choice should be based on a good reason, and lastly the patient should be capable of understanding fully the issues of the question before consenting. If the patient was unable or incapacitated, then the law would allocate a person appointed by the patient or their next-of-kin to make the decision for the patient (substituted judgment). Consenting is truth telling, respecting human dignity and related to autonomy. So informed consent is a shared decision process between the investigator/ physician and the participant. The accepted mode for informed consent is writing and if not documented, witnessed (Pamela Andanda, 2005).

Obtaining informed consent for any medical procedure is a foundation of medical practice. Also consenting in medical trials, should state the purpose of the trial, and its benefits to patients and society, and what might be the possible side effects and consequences, and if so what alternatives should be taken forward to combat such side effects (Joanne Lynn,2006). Also it should state the right to refuse or withdraw later from the trial at any time without prejudice.

Confidentiality
It is the patient's conversation with his/ her doctor, and it is called as patient-physician privilege relationship. Privacy is the key component of any individual autonomy (safeguarded patient privacy). Legal protection would not ask the doctor to reveal his/her patient's complaint. So to disclose any personal information to third parties is prohibited (Mishra NN, Parker LS, Nimgaokar VL, Deshppande SN, 2008). Some exceptional conditions would need doctor cooperation in certain unusual circumstances where the public interest is needed and certified to warrant it, and such situations would be; report a gunshot wound to police, also report a sexually transmitted disease in a patient who refuses to tell the spouse, terminating pregnancy in the underage without acknowledgement to their parents, and abortions (McCarthy RL, 2008). Cultural differences could create a medical ethics problem in terms of their belief. Therefore protection of the privacy and confidentiality of patients is of paramount importance (Harnett JD, Neuman R., 2009).

Prisoner and detainees and medical ethics
According to Tokyo measures and declaration, it stated that no torture or any threat should be inflicted on a prisoner or their members of family, because that is considered as an offence and criminal act to human dignity (Place RJ., 2006, Halpern AL, Halpern JH, Doherty SB., 2008). Torture is defined as severe pain or suffering whether physical or mental, that is inflicted in order to get information or a confession for the third party. From this concept a standard has been structured, and that emphasis is as follows; adopts the principle of medical ethics especially of physicians in order to protect prisoners against torture and degraded actions, calls for all governments to give the principle of medical ethics with consideration to actual resolution to all medical and paramedical professionals, and invites all the intergovernmental organizations, such as the WHO and other NGOs to bring up the principle of medical ethics to medical and paramedical fields.
Health personnel, especially physicians should provide full care to prisoners, and detainees with similar equality to those not imprisoned or detained (Pont J, 2008). Also they should not apply those clinical trials and any harmful drugs to them unless they wanted to participate with their own will and after explicit explanation. Moreover they should not torture or interrogate them in a manner that might adversely effect their physical or mental state. Also they should not get into any kind of relationship that does not involve evaluation, protection and improvement of their physical or mental health.

Ethics concepts in research involving animals/ humans:
Animal experimentation is fundamental to any biomedical sciences and for advancement of human understanding the nature of life and the process of any vital process, and for improvement of any methods and prevention, diagnosis and treatment in humans and animals as well. This is a major exploitation of animals by human beings. Nowadays many countries ban those practices. Also an ethical committee was created to give approval for such actions. A regulatory rule was set where there should be a respect for animals used for any scientific purposes to avoid any discomfort or pain inflicted. This policy would give a frame to the codes of practice and legislation regarding using animals for any scientific purposes (Pitak-Arnnop P, Schouman T, Bertrand JC, Hervé C, 2008).
There is an animal ethical code, which should meet strict ethical requirements. Any human experimentation should be a sine qua non of medical progress, and should follow strict ethical requirements as well (Belmont report), as this was drawn from abuses which were conducted during the second world war on concentration camp prisoners (inhuman Nazi human experimentation) by Dr Josef Mengele; the Nuremberg war crime trials (van Teijlingen ER, Douglas F, Torrance N, 2008). For that, national and international ethical codes and legislation were constructed especially for those with new substances or devices when used for the first time to ensure animal welfare and human being safety; the Nuremberg code (Shankar G, Simmons A, 2009). Those experiments can be either for behavioural, physiological, pathological, toxicological, therapeutic research, experimental surgery, diagnostic, surgical training, testing drugs, biological preparation. Different countries have various policies for animal and human experimentation, and testing which are taken according to their cultural backgrounds (Chertoff J, Pisano E, Gert B,2009). There have been some principles which should be considered in order to improve the means of health and well being and protection of both animals and human beings. All methods should be computerised wherever applicable; selection should follow some rules such as what species to use, and with a minimum number for valid results scientifically. Never fail to treat animals as sentient, nonetheless treat them with proper care and avoid as much as possible pain, distress and discomfort that might be incurred while handling or testing. Always assume those tests that might cause pain in humans, might also cause pain in animals; however perception of pain in animals is still unknown yet. Whenever pain might be caused, always consider applying testing with appropriate sedation, analgesia or anaesthesia. When animals are in chronic pain, and disablement, they should be relieved by painless killing. Provide best possible living conditions with space allocationsfor each animal with adequate standard of hygiene. Veterinarians should be available when needed. In order to conduct procedures on animals, it's obligatory to ensure appropriate qualifications and experience. Quarantine and isolation should be in hand when demanded in an emergency. Entry should be only for authorized persons. Ensure good environmental conditions such as temperature, ventilation, lightening, noise, odour level, disposal of waste. Also ensure a good supply of food in terms of quantity and quality to preserve health with an access to free clean potable water. Keep a record of all kept animals with their testing and progress of testing results and if they died a post-mortem examination. Research would only be justified if there was a well-built possibility that it would contribute to improvements of the human condition, whether trial participants and future patients (Udo Schüklenk, 2005).
Research ethics is fundamentally about the means of ensuring that defenceless people are protected from exploitation and other forms of harm. Therefore they should be informed of every single detail and ensure their understanding of the possible outcomes.

Alternatives
Nowadays the trend is to use isolated cells, tissue or organs in experimentation. This would replace the use of an intact live animal for any experimental procedures. Those alternatives would include non-biological and biological methods. The former would include mathematical modelling of structure activity relationships based on the physio-chemical properties of drugs, and other chemical, computer modelling of other biological process. The latter implies use of micro-organisms, and in-vitro preparations (sub-cellular fractions, short term cellular systems, whole organ perfusion, cell and organ culture, and also retrospective and prospective epidemiological investigation on human and animal populations, represents another approach. The idea of alternatives is adopted to be a complementary technique to the use of intact animals. This in my opinion should be applied and encouraged to use for both scientific and human reasons in order to ease the animal and human being misery and suffering (Kurosawa TM., 2008).

Legal medicine
It is an interface between medicine and law in health care. Reviewing athletes' fitness and ensuring that prohibited substances are not prescribed, symbolize a growing area of legal medicine. Ethical thoughtfulness of health care should respect legal medicine principles. Migration and communicable diseases are aspects of legal medicine. International meetings must be respected by legal medicine and dictate a physicians' duties. Legal medicine is a medical specialty in its own right (Beran RG, 2008).

Standards of conduct and duties of doctors
Duties should always be purely humane. Doctors must always strive to maintain the highest standard of professional conduct, and should not be influenced by any means by either motives or profits (Judicial Council, 1957). They should always bear in mind the obligation to preserve human life from the time of conception and development. Any abortion which threatens a mother's life should be considered under the conscience of doctors and as statute law permits. Doctors should owe the patient their complete loyalty and the resources of science. They should help when needed especially in emergency situations. A doctor should behave to colleagues as he/she would have them behave to them. A doctor must not entice patients from his colleagues. Doctors should follow the declaration of Geneva, approved by the world medical association in 1948. It is a revision of Hippocrates' oath. It stated that doctors should practice their profession concisely and with dignity, bearing in mind sole consideration to their patients and their professions, and should not refer their patients for some costly treatment, or investigation and take charges for that, as this is unethical (Judicial Council, 1957). Also marketing for some pharmaceutical companies and receiving gifts and food for that is unethical and unacceptable. This means influencing prescribing practice for some companies' products. Doctors should not get involved in a sexual relationship with their patients because this creates ethical conflicts. In some countries such acts and violation would mean deregistration and prosecution. Treat colleagues as your brothers and sisters. Do not allow religion, nationality, ethnicity, age, gender and racial barriers to intervene with your duty to your patient.

Medical futility
Medical futility is a very important topic in medical ethics. How would we as physicians act if a terminally ill patient and his family insist on advanced care. Previously futility meant that a patient might have less than 1% chance of survival. Some of such cases wound up in the courts. So living wills and durable powers of attorney for health care were considered. Therefore in such critical situations, decisions should be made between doctors, and clinical ethics committees or other independent parties to resolve the conflicts about withdrawing or continuing treatment within the legitimate policy (Miljeteig I, Johansson KA, Norheim OF., 2008, Davis JK., 2008).

Health system, misconduct and ethics in Libya
The healthcare system in Libya is still missing its real form and meaning. Some rated the health standards to be extremely poor. This could be attributed to our culture and society. For instance, we never tend to inform the patients of their real illness, instead we tell relatives, and sometimes their neighbour if they were accompanying them. Not only that, we might extend it to a social discussion on the communal events meeting up. Therefore confidentiality and privacy is broken, breached and jeopardised. This would mean breaking rules of the Hippocrates oath; anyway no one could be blamed, because after all I don't recall we had this oath when we graduated. It was stated only once for the first graduate of the medical school. This could be the only reason to be blamed in such critical occasions. Also our patients lost their trust in the Libyan health system and service delivery, due to the following reasons;

• Lack of independent regulatory body within the ministry of health, and professional bodies
  
• No effective appraisal or revalidation of the medical manpower
  
• No robust governance body
  
• Poor environmental setup, for the patient and health providers
  
• Lack of consistency and continuity of care
  
• Poor communication systems and patient data records
  
• Lack of evidence based practice
  
• Lack of vision and of decision making processes
  
• Under funding and corruption
  

The health sector is a very important element for the growth and upholding of any nation. For instance any country would allocate a budget for its health system in order to improve it in terms of productivity. In Libya it is the expenditure and not the production. Whom you need to blame, no one knows. This emphasises and calls for an existence of a concrete, clear, ethical and well-formed discipline to be followed and implemented. Also nowadays our patients tend to go to the neighbouring countries such as Tunisia, Egypt and Jordan for any medical check-up and treatment. This would only indicate losing the trust in the Libyan doctors. Therefore the society and government should unite and provide decent living standards for Libyan doctors to produce and be fruitful. For instance, low income and high living costs would make a serious discrepancy. Furthermore the government raised the doctors and nurses salary as a test for some hospitals and not for everyone, and this creates hatred and discrimination. There isn't any effective health system that would behave in that manner in the whole world. Moreover we tend not to have a registry and medical recoding system per se, and if itexisted, it would be only a pile of files where concise and precise accountable documentation is missing and therefore it would lose its real meaning and application. This is another ethical problem in our health practice in Libya. Therefore for any patient who has travelled abroad for treatment, this would mean a duplication of an unavoidable investigation and treatment again which could be costly as well. Furthermore electronic documentation is still missing. The old adage is if it's not documented, it was not done. It's a fact and this should be followed and implemented. Libyan doctors tend to be reactive instead of proactive. We need to evolve medical practice in Libya.
We need to voice our opinions and discuss all that matters and consider ethical values and apply them in order to create a healthy society in our community. It's actually a very complicated process as it does involves a lot of factors, and if one is fixed, you can't necessarily fix the rest. This all goes back to our background cultural heritage (Rispler-Chaim V., 1989).
Physicians always face ethical dilemmas when dealing with their patients. They should adopt and conduct moral rules and develop attitudes within the framework of ethical concept, and aims to implement in their normal practice, in order to improve and understand its application.
Ethics is distinctive material specifically because of its widespread acquaintance in all aspects of our life, and therefore any teaching has to start from the concept of ethical understanding to guarantee intellectual respectability.

Recommendations: IMPLEMENTATION OF ETHICS REVIEW
There should be a taught course on basic ethics and values, and the principles of practice in the medical study years especially when facing clinical medicine. In the Islamic world, medical curricula should embrace the Islamic code of medical ethics. However our religion after all emphasises such values to be implemented, but it seems they are still missing on application. We therefore should urge and stress the need to develop and adopt a universal national guideline for ethics codes learning, exploring and applying, while practising medicine. It would be highly appreciable if a manual for medical ethics is considered in order to serve a guiding tool for both medical students and physicians.
Improving quality of care is a policy objective of health care systems around the world. Advanced quality of care is a doctrine and aim of health care systems around the world. Implementation research is the scientific study of methods to encourage the systematic uptake of clinical study findings into routine clinical practice, and thus to reduce inappropriate care.
Currently our patient receives less than desirable care due to lack of consolidated clinical records, plus the fact that there is no electronic medical data record system. In order to improve any health service quality there must be a clinical research ethics policy, and that should be evaluated thoroughly (Daw A, Elkhammas EA, 2008).
We should develop a review ethics committee board to evaluate and assess medical practice on human beings, and establishing a hospital ethics committee to emphasise the role of the ethicists in the medical curricula. Effective hospital accreditation would require ethical consideration taken into account seriously; otherwise ethics would be in crisis.
Researchers must strictly adhere to the diverse ethical guidelines to ensure the dignity and rights of human participants are correctly upheld in research. Ethics teaching plans to teach physicians to spot and resolve ethical issues; they also should address any ethical concerns and confront each other when debates raise (Sarah L. Clever, Kelly A. Edwards, Chris Feudtner, Clarence H. Braddock III, 2001).

Principles: Time for ethics to face the forthcoming future
There should be some guidelines for medical doctors to practice, and they are briefly as follows:
Listen carefully to patient complaints and worries

1. Respect autonomy
   
2. Deal with patient with great care and respect
   
3. Tell the full story and the complete truth to patients
   
4. Apply basic principles and methods from our Islamic religion
   
5. Start with yourself, correct your own ethics and commit to improving your own manners in
6. order to improve ethics
   
7. Develop one committee to teach across the country
   
8. Follow our precious previous pioneers' footsteps such as Ibn Sina, as they represent the ideal physician to be inspired and followed
   
9. We need to set up rules and vital points in considering the psychology of patients to make them feel better and improve things for them
   
10. Pay more attention and care to your patients
    
11. Try to make availability of standard medical services as a shortage of them would mean the system is imperfect and breached
    
12. Develop a standard of conduct and approaches, for application of medical ethics

Acknowledgement
A special thank goes to Dr Dardouri. H. who proof read my review and edited some points, and believed on me and supported me.

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