Editörler/Editors. Hanzade Doğan Fatih Selami Mahmutoğlu Arın Namal. In alphabetical order

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2 Türk Tıp Etiği ve Tıp Hukuku Araştırmaları Yıllığı The Turkish Annual of the Studies on Medical Ethics and Law Türkisches Jahrbuch für Studien zu Ethik und Recht in der Medizin Editörler/Editors In alphabetical order Hanzade Doğan Fatih Selami Mahmutoğlu Arın Namal

3 2009 Nobel Tıp Kitabevleri Ltd. Şti. TÜRK TIP ETİĞİ VE TIP HUKUKU ARAŞTIRMALARI YILLIĞI Editörler/Editors: In alphabetical order Tıp Etiği/Medical Ethics: Hanzade Doğan, Arın Namal Hukuk/Law: Fatih Selami Mahmutoğlu ISSN: X Bu ki ta bın, 5846 ve 2936 sa yı lı Fi kir ve Sa nat Eser le ri Ya sa sı Hü küm le ri ge re ğin ce yazarın yazılı izni olmadan ki ta bın bir bö lü mün den alın tı ya pıla maz; fo to ko pi yön te - miy le ço ğal tı la maz; re sim, şe kil, şe ma, grafik, vb. ler kopya edilemez. Her hakkı Nobel Tıp Kitabevleri Ltd Şti ne aittir. Dü zen le me: Kapak: Bas kı / Cilt: No bel Tıp Ki ta bev le ri Özkan Kaya Özkan Kaya No bel Mat ba acı lık, Ha dım köy-is TAN BUL NOBEL TIP KİTABEVLERİ LTD. ŞTİ. ÇAPA Millet Cad. No:111 Çapa-İstanbul Tel: (0212) Fax: (0212) CERRAHPAŞA Cerrahpaşa Tıp Fakültesi Karşısı Park içi Cerrahpaşa-İstanbul Tel: (0212) KADIKÖY Rıhtım Cad. Derya İş Merkezi No: 7 Kadıköy-İstanbul Tel: (0216) SAMSUN Ulugazi Mah. 19 Mayıs Bulvarı 16/6 Tel: (0362) ELAZIĞ Yahya Kemal Cad. Üniversite Mah. No: 36/B Tel: (0424) Ankara MN MEDİKAL & NOBEL TIP KİTABEVİ Halk Sok. No: 5 Sıhhiye-Ankara Tel: (0312) İzmir / Bornova İZMİR GÜVEN KİTABEVİ 168. Sok. No: 10/1 Bornova-İzmir Tel: (0232) İzmir / Konak İZMİR GÜVEN KİTABEVİ SSK İş Hanı P/36 Konak-İzmir Tel: (0232) Adana ADANA NOBEL YAYIN DAĞITIM Adnan Kahveci Bulvarı 31/C Adana Tel: (0322) Bursa GÜNEŞ & NOBEL TIP KİTABEVİ Altıparmak Cad. Burç Pasajı, Bursa Tel: (0224)

4 Türk Tıp Etiği ve Tıp Hukuku Araştırmaları Yıllığı The Turkish Annual of the Studies on Medical Ethics and Law Türkisches Jahrbuch für Studien zu Ethik und Recht in der Medizin Vol.1 No.1 Ekim / October / Oktober 2008 Founder / Gründerin Ayşegül Demirhan Erdemir Uludağ University Medical Faculty Department of Medical Ethics and Medical History Editörler/Editors (In alphabetical order) Hanzade Doğan Istanbul University Cerrahpaşa Medical Faculty Department of Medical Ethics and Medical History Fatih Selami Mahmutoğlu Istanbul University Faculty of Law Department of Criminal Law, Criminal Procedure Law Arın Namal Istanbul University Istanbul Medical Faculty Department of Medical Ethics and Medical History Yardımcı Editörler / Assistant Editors / Schriftleitung (In alphabetical order) Elif Atıcı Uludağ University Medical Faculty Department of Medical Ethics and Medical History Murat Civaner Uludağ University Medical Faculty Department of Medical Ethics and Medical History International Advisory Board / Internationaler Beirat (In alphabetical order) Osman Faruk Akyol (Turkey) Nevzat Alkan (Turkey) Ayten Altıntaş (Turkey) Berna Arda (Turkey) Erdem Aydın (Turkey) Jayapaul Azariah (India) İbrahim Başağaoğlu (Turkey) Koksal Bayraktar (Turkey) Gerhold Becker (Thailand) Erwin Bernat (Austria) Nikola Biller-Andorno (Switzerland) Cengiz Cakmak (Turkey) Mebrure Değer (Turkey) Ahmet Dinççağ (Turkey) Gunnar Duttge (Germany) Dietrich v.engelhardt (Germany) Akile Gürsoy (Turkey) Hamit Hancı (Turkey) John Harris (U.K.) Hakan Hakeri (Turkey) Caris Petra Heidel (Germany) Esin Kahya (Turkey) Ingrid Kästner (Germany) Christian Kopetzki (Austria) Adem Koyuncu (Germany) Ulrich Körtner (Austria) Gisela Bockenheimer Lucius (Germany) Darryl Macer (Japan) Yasemin Oğuz (Turkey) Öztan Öncel (Turkey) Zuhal Özaydın (Turkey) Henning Rosenau (Germany) Nil Sarı (Turkey) Hans Ludwig Schreiber (Germany) Yıldız Silier (Turkey) Dieter Sturma (Germany) Sevgi Şar (Turkey) Brigitte Tag (Switzerland) Jochen Taupitz (Germany) Verena Tschudin (U.K.) İlter Uzel (Turkey) Ismail Yakıt (Turkey) Claudia Wiesemann (Germany) Urban Wiesing (Germany) Yazı Takip Sekreteri / Editorial Secretary/ Redaktionssekretariat Sezer Erer Uludağ University Medical Faculty Department of Medical Ethics and Medical History

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6 İçindekiler/Contents/Inhalt Önsöz...vii Preface...viii Vorwort...ix Kapak Resmi...x Cover Picture...xi Umschlag...xii Highly Valued Virtues of Classical Ottoman Turkish Medical Ethics a View from Past to Future Türkçe Tıp Yazmalarına Göre Osmanlı Hekiminden Beklenen En Değerli Erdemler Dünden Geleceğe Bir Bakış...1 Nil Sarı Recht und Ethik der Fortpflanzungsmedizin zu Beginn des 21. Jahrhunderts eine Bestandsaufnahme 21. yy. Başında Üreme Tıbbının Hukuku ve Etiği- Bir Envanter...17 Erwin Bernat Die Ausstellung des Sterbenden und der Leiche - Rechtliche und Ethische Fragen Ölenlerin ve Cesetlerin Sergilenmesi - Hukuki ve Etik Sorular...35 Brigitte Tag Das Selbstbestimmungsrecht des Patienten: Aktuelle Kontroversen im deutschen Recht Hastanın Kendi Hakkında Karar Verme Hakkı: Alman Hukukunda Güncel Tartışmalar...43 Jochen Taupitz Moleküler Genetik İncelemenin Ceza Muhakemesi Hukuku Bağlamında Analizi Analysis of Molecular Genetic Examination Relevant to Criminal Procedure Law...53 Fatih Selami Mahmutoğlu An Approach to the Relationship among the Music, Treatment and Ethics in Medieval Islam Ortaçağ İslam Dünyasındaki Müzik, Etik ve Tedavi Arasındaki Münasebete Bir Yaklaşım...63 Esin Kâhya Das Arzthaftungsrecht in Deutschland - Ein Überblick Alman Hukukunda Hekim Sorumluluğu - Bir Genel Bakış...73 Adem Koyuncu v

7 İçindekiler/Contents/Inhalt Geschenk oder Geschäft? Zur Diskussion um den Verkauf Menschlicher Organe Armağan Ya da Ticaret? İnsan Organlarının Satışı Hakkındaki Tartışmalar Üzerine...83 Nikola Biller Andorno Aydınlatılmış Onamın Belgelendirilmesinde Etik Açıdan Düşündürücü Yönler Aspekte der Dokumentation von Einwilligung nach Aufklärung die in Ethischer Hinsicht zu denken geben...95 Arın Namal Menschenwürdiges Sterben - Typologie des Rechts und Normative Grundlagen - İnsan Onuruna Yaraşır Şekilde Ölmek -Hukukun Tipolojisi ve Normatif Temelleri Gunnar Duttge Purity, Duplication -Multiplication and Hybridization of Genome: Medical Ethics and Law Genomun Saflığı, Kopyalanması - Çoğaltılması ve Melezlenmesi: Tıp Etiği ve Tıp Hukuku Jayapaul Azariah, V. Manickavel The Developments in the Physician-Patient Relationship of Turks in the Light of Archive Documents Arşiv Belgeleri Işığında Türklerde Hekim-Hasta İlişkilerinde Gelişmeler Ayşegül Demirhan Erdemir Primary Healthcare Displaced Within Public Health Matters: A report from Turkey with its ethical implications Halk Sağlığı Sorunları Arasında Yeri Değişmiş Birinci Basamak Sağlık Hizmetleri: Etik Açıdan Değerlendirmeler ile Birlikte Türkiye den Bir Bakış Açısı Hanzade Doğan Quality Analysis on the Communication Among Science/Technology, Spirituality and Bioethical Decision-Making in a Fair Society Adil Bir Toplumda Bilim/Teknoloji, Dini ve Biyoetik Karar Verme Arasındaki İletişim Üzerine Kalitatif Analiz Bing Tang Etik Haftası Kutlu Olsun! Kamu Görevlileri Etik Kurulu ve Çıkmazı Government Official Ethics Committee and Some Problems Ayten Altıntaş Controversial Harvest Moral Implications of Organ Procurement Strategies Organ Temini Stratejilerinin Ahlaki Anlamı Üzerine Tartışmalar Gerhold K. Becker Yaşlılık Etiği Geriatric Ethics Nüket Örnek Büken Yazarlar İçin Kurallar vi

8 Önsöz Değerli Okuyucular Türkiye de tıp etiği ve tıp hukuku alanlarındaki bilimsel etkinlikleri güçlendirmek amacıyla 2004 yılında kurulan Tıp Etiği ve Tıp Hukuku Derneği, Türkiye nin çeşitli üniversitelerinde bu alanlarda çalışan bir çok değerli bilim adamını çatısı altında toplamayı başarmıştır. Dernek ikisi uluslar arası katılımlı sempozyum olarak Istanbul da (Istanbul Üniversitesi Istanbul Tıp Fakültesi, Istanbul Üniversitesi Cerrahpaşa Tıp Fakültesi, İstanbul Üniversitesi Hukuk Fakültesi ve Uludağ Üniversitesi Tıp Fakültesi işbirliğiyle), diğeri uluslar arası kongre olarak Antalya da (Akdeniz Üniversitesi Tıp Fakültesi, Akdeniz Üniversitesi Hukuk Fakültesi, Institut für Deutsches, Europaeisches und Internationales Medizinrecht, Gesundheitsrecht und Bioethik der Universitaeten Heidelberg und Mannheim-IMGB ve All Indian Bioethics işbirliğiyle) 2005, 2006 ve 2007 yıllarında peş peşe üç önemli toplantı gerçekleştirmiştir. Derneğin yılda iki kez 30 sayfa civarında yayınlanan, 7. sayısına ulaşmış bir Bülten i bulunmaktadır. Dernek, gittikçe güçlenen çalışmalarının bir parçası olarak, uluslar arası bir Editorial Kurula sahip olan bu yıllığı çıkarmakla büyük ve onurlu bir görevi de yerine getirmektedir. TÜRK TIP ETİĞİ ve TIP HU- KUKU ARAŞTIRMALARI YILLIĞI adı altında okurlarla buluşacak olan yıllığımız, Tıp Etiği ve Tıp Hukuku Derneğinin yayın organı olacaktır. Yıllık, tıp etiği alanındaki temel sorunları ve güncel gelişmeleri disiplinler arası işbirliği ile ele almak, gittikçe karmaşıklaşan ve farklı bakışların eklenmesini bekleyen tıp etiği tartışmalarına olabildiğince ülkemizin ve diğer ülkelerin sorunlara bakışını yansıtma amacını taşımaktadır. Yıllığın editoryal kurulunda yurt içinden ve yurt dışından değerli araştırıcılar bulunmaktadır. Yıllık, yayın dilini Türkçe, İngilizce ve Almanca olarak belirleyerek, oluşturduğu platformu bu alanda düşünce ürünü ortaya koyan tüm ulusların bilim insanları ile paylaşmayı amaçlamaktadır.. Bu özelliği ile Türkiye de tıp etiği ve tıp hukuku alanında Türkçe, İngilizce ve Almanca olarak yayınlanan nadir dergilerden biri olmaktadır.. Yılda bir kez okurla buluşacak olan.yıllığın bu ilk sayısında yurt dışından ve yurt içinden değerli bilim insanlarının yazıları vardır., Türk Tıp Etiği ve Tıp Hukuku Araştırmaları Yıllığı nın tüm meslektaşlara ve herkese yararlı olması dileğiyle. Kurucu Aysegül Demirhan Erdemir vii

9 Preface Dear Readers Society for Medical Ethics and Law, which was founded in 2004 to support all the scientific activities in Turkey about medical ethics and law, has succeeded in bringing together many distinguished scientists who work on those issues in different universities of Turkey. The Society has held three successive international congresses in 2005, 2006 and 2007, of which two were in İstanbul (with the cooperation of İstanbul University İstanbul Medical School, İstanbul University Cerrahpaşa Medical School, İstanbul University Law School and Uludağ University Medical School), and one was in Antalya (with the cooperation of Akdeniz University Medical School, Akdeniz University Law School, Institut für Deutsches, Europaeisches und Internationales Medizinrecht, Gesundheitsrecht und Bioethik der Universitaeten Heidelberg und Mannheim-IMGB and All Indian Bioethics). The Society has a bulletin of nearly 30 pages published twice a year and its fifth volume has been published. As a part of its studies getting more and more efficient, the Society has also planned to publish an Annual with an international Editorial Board. The Annual, with the name of, THE TURKISH ANNUAL OF THE STUDIES ON MEDI- CAL ETHICS AND LAW is going to be the official publication organ of the Medical Ethics and Law Society. The Annual aims to deal with in cooperation with other disciplines the main problems and current developments in the field of medical ethics, and reflect as much as possible our country s point of view regarding the medical ethics discussions that are getting more and more complicated and requiring some different viewpoints. The publication languages were determined to be Turkish, English and German, with which it is aimed to share our platform with all the scientists thinking over the field. It is one of the few journals on medical ethics and law in Turkey that are issued in the languages of Turkish, English and German. It is going to be published once a year by NOBEL MEDICAL PUBLISHING, which is the leader medical publishing house of Turkey. We invite you, as a distinguished scientist in the field of medical ethics/law, to be a member of the Editorial Board of our Annual. In the attachment, you can see the publishing rules in Turkish, German and English languages, and the other people who have been offered to take part in the Editorial Board. A positive response of yours would honor and encourage us. Your support would also build bridges between our country and yours for cooperation in the field of medical ethics and law. Best Regards, Founder Aysegül Demirhan Erdemir viii

10 Vorwort Verehrte Leserinnen und Leser, dem 2004 mit dem Ziel der Stärkung wissenschaftlicher Aktivitäten in den Bereichen Recht und Ethik der Medizin in der Türkei gegründeten Verein Recht und Ethik der Medizin ist es gelungen, zahlreiche angesehene Wissenschaftler, die an den diversen Universitäten der Türkei in diesen Bereichen tätig sind, unter seinem Dach zu versammeln. 2005, 2006 und 2007 wurden drei wichtige Tagungen abgehalten, zwei davon als Symposien mit internationaler Beteiligung in Istanbul (in Kooperation mit der Medizinischen Fakultät Istanbul der Universität Istanbul, der Medizinischen Fakultät Cerrahpaşa der Universität Istanbul, der Juristischen Fakultät der Universität Istanbul und der Medizinischen Fakultät der Uludağ-Universität), die dritte als internationaler Kongress in Antalya (in Kooperation mit der Medizinischen Fakultät der Akdeniz-Universität, der Juristischen Fakultät der Akdeniz-Universität, dem Institut für Deutsches, Europäisches und Internationales Medizinrecht, Gesundheitsrecht und Bioethik der Universitäten Heidelberg und Mannheim-IMGB und All Indian Bioethics). Der Verein verfügt über ein Bulletin, das zweimal jährlich mit rund 30 Seiten publiziert wird und mittlerweile in der siebten Ausgabe erschien. Mit der Herausgabe dieses Jahrbuches mit einem internationalen Editorial Board als ein Teil seiner beständig wachsenden Aktivitäten erfüllt der Verein eine große und verdienstvolle Aufgabe. Unser Jahrbuch, das sich der Leserschaft unter dem Titel TÜRKISCHE JAHRBUCH FÜR STUDIEN ZU RECHT UND ETHIK DER MEDIZIN präsentiert, wird Publikationsorgan des Vereins Recht und Ethik der Medizin sein. Ziel des Jahrbuches ist es, Grundfragen und aktuelle Entwicklungen der medizinischen Ethik in interdisziplinärer Zusammenarbeit zu behandeln und den Blick im In- und Ausland auf die medizinethische Diskussion, die zunehmend komplexer wird und nach unterschiedlichen Perspektiven verlangt, soweit wie möglich widerzuspiegeln. Dem wissenschaftlichen Beirat des Jahrbuchs gehören angesehene Wissenschaftler aus dem In- und Ausland an. Publikationssprachen des Jahrbuches sind Türkisch, Englisch und Deutsch. Dadurch soll in diesem Bereich produktiv tätigen Wissenschaftlerinnen und Wissenschaftlern aller Länder die Möglichkeit gegeben werden, dieses Forum zu teilen. Diese Eigenschaft macht das Jahrbuch zu einem der wenigen jener Periodika, die in der Türkei auf den Gebieten Recht und Ethik der Medizin in türkischer, englischer und deutscher Sprache publiziert werden. In dieser ersten Ausgabe des Jahrbuches finden sich Aufsätze bekannter Wissenschaftler aus dem In- und Ausland. Unser Wunsch ist, dass das Jahrbuch für Türkische Studien zu Recht und Ethik der Medizin allen Kollegen und der Öffentlichkeit von Nutzen sein möge. Gründerin Ayşegül Demirhan Erdemir ix

11 Ressam JALE YAVUZ Yükseköğrenimini sürdürürken 1980 yılında Cerrahpaşa Tıp Fakültesi, Tıp Tarihi ve Deontoloji Anabilim Dalında, Ord. Prof. Dr. Süheyl Ünver in Türk Süsleme Sanatları Seminerleri ne katıldı. Ülker Erke ve Gülbün Mesara nın Tezhip ve minyatür derslerine devam etti. Yurtiçinde çeşitli müze ve kütüphanelerde, yurtdışında Viyana Üniversitesi nde, Avusturya Milli Kütüphanesi El Yazmaları Bölümü nde ve Graz Üniversitesi nde, Türk- İslam eserlerinin çeşitli yüzyıllara ait ender güzellikteki özgün örneklerini araştırdı. Özellikle Geçme Motifleri konusunda karşılaştırmalı incelemelerde bulundu. Kişisel sergiler açtı. Yurtiçinde ve yurtdışında grup sergilerine katıldı. Çeşitli kentlerde gerçekleştirilen Ulusal ve Uluslar arası Türk Tıp Tarihi Kongresi etkinlikleri kapsamında hazırlanan çeşitli sergilerde ve kitaplarda eserlerine yer verildi. Halen Yıldız Teknik Üniversitesi Mimarlık Fakültesinde Yapı Çözümlemesi Dersi kapsamında yürütülen Atölye çalışmalarında sanatçı-hoca, Cerrahpaşa Tıp Fakültesi Tıp Tarihi ve Deontoloji Anabilim Dalı bünyesinde Ord. Prof. Dr. Süheyl Ünver Nakışhanesinde öğretim görevlisi olarak sanat çalışmalarını sürdürmektedir. Kapak Resmi HAYAT AĞACI Doğada birbirlerinden farklı görünümde yaşam türleri olarak varlıklarını sürdüren canlılar, minyatürlerimde doğanın bir parçasının estetik kompozisyonu gibi görünse de gerçekte, insanın toplum içindeki yaşam biçimini, yaşadığı sınırlar içinde davranış şekillerini, özgürleşme ve varlığını sürdürme çabalarını karakterize eden, simgeleyen örneklerdir. Bu özgün tasarımda, yaşamın sürekliliği ile yinelenen doğum, gelişim ve bitim çerçevesi içinde, yaşlı bir ağacın desteği ile yaşamını geliştiren gür bir ağaçta yardımlaşma ve sığınma sevinci konusu işlenmiştir. Bu minyatür Prof. Dr. Müzeyyen Erk Kolleksiyonundadır. x

12 Artist JALE YAVUZ When she was having her license education in 1980, she attended seminers of Turkish Ornament Art organized by Emeritus Prof. Dr.Süheyl Ünver in the Department of Deontology and Medical History. She attended the lectures of gilding and miniature organized by Ülker Erke and Gülbün Masera. She made research about authentic Islamic work and products belonging different centuries both in Turkish museums, libraries and in the University of Vienna, in the Austrian national library (section of manuscripts) and in the University of Graz. She made comparative work on art of dovetailed motives. She opened personel exhibitions. She attended exhibitions of groups both in Turkey and other countries. Exhibitions and books that were prepared In the National and Inter national congresses of Turkish Medical History contained some of her work. She still teaches art in the Yıldız Teknik University in the Department of Architecture in the workshops organized in the lectures of Construction Analysis. She is also a lecturer of art in the workshop group that had been established by Emeritus Prof. Dr. Süheyl Ünver in the Department of Deontology and Medical History. Cover Picture: The TREE of LIFE Living organisms surviving in the nature as different types seem as aesthetic composition of nature in my miniatures but in fact they are symbols that characterize human life and behaviours in the society, struggle of human for freedom and to exist. In this authentic composition, in the context of birth, development and end that repeats by the continuity of life, the topic of the joy of a thick tree about help and shelter that gets help from an old tree is worked and presented. This miniature is in Prof. Dr. Müzeyyen Erk s collection xi

13 Malerin JALE YAVUZ Nahm während ihres Studiums 1980 an den Seminaren zur Türkischen Ornamentik von Ord. Prof. Dr. Süheyl Ünver im FB Deontologie und Geschichte der Medizin der Med.Fak. Cerrahpaşa teil. Nahm Unterricht in Miniatur und Ornamentik bei Ülker Erke und Gülbün Mesara. Recherchierte Werke von eigener, seltener Schönheit der türkisch-islamischen Kunst aus verschiedenen Jahrhunderten in diversen Museen und Bibliotheken im Inland sowie im Ausland an der Universität Wien, in der Handschriftenabteilung der Österreichischen Nationalbibliothek und an der Universität Graz. Stellte vergleichende Studien inbesondere zu Übergangsmotiven an. Eigenständige Ausstellungen sowie Beteiligung an Gruppenausstellungen im Inund Ausland. Ihre Werke wurden in Bücher und Ausstellungen im Rahmen der Aktivitäten des Nationalen und Internationaln Türkischen Kongresses Geschichte der Medizin aufgenommen. Derzeit ist sie künstlerische Leiterin bei den Atelierarbeiten im Rahmen der Stukturanalyse- Lehre an der Fakultät für Architektur der TU-Yıldız, Istanbul, und Lehrbeauftragte im Ornamentatelier Ord. Prof. Dr. Süheyl Ünver im FB Deontologie und Geschichte der Medizin der Med.Fak. Cerrahpaşa. Umschlag unter Verwendung des Gemäldes DER BAUM DES LEBENS Die Lebewesen, die ihre Existenz in der Natur als unterschiedlich erscheinende Lebensweisen führen, sind, auch wenn sie auf meinen Miniaturen wie ästhetische Kompositionen eines Teils der Natur wirken, tatsächlich doch Symbole für die Lebensweise des Menschen in der Gesellschaft, seine Handlungsweisen, seine Freiheits- und Überlebensbestrebungen. In diesem originellen Konzept sind im Rahmen von Geburt, Entwicklung und Tod, die sich mit der Kontinuität des Lebens wiederholen, die Themen freudiger Unterstützung und Inanspruchnahme von Hilfe anhand eines mächtigen Baumes bearbeitet, der sein Leben mit Hilfe eines alten Baumes entfaltet. Diese Miniature gehört Prof. Dr. med. Müzeyyen Erk s Sammlung. xii

14 Highly Valued Virtues of Classical Ottoman Turkish Medical Ethics a View from Past to Future Nil Sarı Head of the Medical Ethics and History Department, Istanbul University, Cerrahpaşa Medical School Türkçe Tıp Yazmalarına Göre Osmanlı Hekiminden Beklenen En Değerli Erdemler Dünden Geleceğe Bir Bakış Özet Osmanlı tıp ahlakının temeli, kendisinde belirli erdemlerin var olması beklenen sağlık çalışanına güven üzerine oturmuştu. Bu bakımdan, hekimce gözetilmesi beklenen doğru davranış örnekleri, belirli erdemlerden çıkarılan ve eylem rehberi olarak değerlendirilen kurallara dayanırdı. Bir hekimin erdemli bir hekim olabilmesi için hangi erdemlerle donatılması en büyük önemi taşırdı? Bunun için bir hekimin en başta, alçakgönüllü, kanaatkar, ümit verici/destekleyici, hastasına sadık olması beklenirdi. Hekimin bu dört erdeme sahip bulunması, Osmanlı hekim yazarlar için olmazsa olmaz sayılır. Bu çalışmada, konuyla ilgili örnekler Osmanlı dönemine ait Türkçe tıp yazmalarından aktarılmakta ve günümüz tıp etiği bağlamında tartışılarak, bugün de bu erdemlerin hekimlikte olmazsa olmaz olduğu gerekçeleriyle vurgulanmaktadır. Anahtar Sözcükler Osmanlıca tıp yazmaları, Türk tıp etiği tarihi, erdemler, alçak gönüllülük, kanaatkârlık, sadakat, ümitli olmak. Introduction Ottoman medical ethics was based on the trust of people to medical practitioner believed to be virtuous. Moral behavior expected to be observed by medical practitioner depended on virtues turned into rules as guides for action. 10 What kind of virtues might be highly effective for training one to be a virtuous physician? The four virtues, modesty, contentedness, hopefulness and fidelity were specifically noted by Ottoman physician writers as inevitable for being qualified as a virtuous physician. Several examples dealing with the subject are quoted from Ottoman medical manuscripts, and discussed with respect to contemporary medical ethics in this essay. 1

15 Virtues Ignored as a Result of Changing Values Experience is as important as experimentation in gaining knowledge. Social sciences specially owe much to historical experience, both individual and social. Ignoring past experience means failure in utilizing valuable knowledge accumulated by man in history. Utilizing past experience is also important for studies on medical ethics. Patient-medical practitioner interrelation and its mutual moral elements in medical history have developed as a result of interaction in the course of time. Today great change has taken place in the field of medical ethics due to the fast development of medical knowledge and technology. Some values lost importance, while others came to be favored and new values have developed, which regressed some virtues, while fostered others. 24 Ottoman Turkish physician compilers described and suggested what ought to be done or not, that is, proper and improper behavior in medical practice. When ethical advices (vasiyyet) in Ottoman medical manuscripts are studied, one can find principles included in these advises guiding health practitioners to virtuous behavior. Ottoman Turkish expectations for medical morality were concentrated on the virtuous behavior of a practitioner. 10 In this study, the virtues modesty, contentedness, fidelity and hopefulness, considered to be a necessity in Ottoman Turkish patient-practitioner relationship, are quoted as ignored today. During the last quarter of the 20th century great progress has been achieved in the field of medical ethics studies, and great effort has been paid in developing ethical principles and rules to lead decision making in the medical field. Contemporary medical ethics concentrated on solving moral dilemmas in accordance with ethical principles and rules. 11 Actions came to be prescribed for certain cases, described within the frame of specific groups of ethical conflicts. The practitioner having justified his/her action on the basis of principles and rules, a probable risk of omitting virtuous behavior needed for ethical patient-practitioner relationship, arose. Prefering principles and rules for guidance in developing ethical behavior for medical practitioner, the quality of practice, that is how to act has come to be ignored. Yet, physician s behavior is perceived as a physical and literal language of the practitioner by the patient, not as ethical principles suitable for the case. Ethical principles and rules isolated from virtuous behavior patterns will speed up the regress of the values that virtues are derived from. There are some declined moral values which led to virtuous behavior in the past that played highly important role in patient-practitioner relationship. However, they are no less important today, as it may harm the patient when they are ignored. Some of the ignored virtues fostered by some values are indispensable in acting within the frame of ethical principles properly. Modesty Nil Sarı A physician has always been authorized and effective, having means and tools which might be useful or harmful, such as drugs and surgical instruments. It is the belief in the role of Godly power on the acts of man, though, that drove Ottoman Turkish physicians away from considering himself esteemed. Modesty was a highly valued virtue, because the duty of physician was conceived as being a caliph of the Creator, whose will was believed to realize the treatment. The Ottoman Turkish physician was expected to perceive himself as a caliph of God in the act of healing and not conceive himself as the real healer. Although the cause of disease was considered to be the imbalance in humours and it was the nature/temperament of the patient 2

16 regarded as important in treatment, the belief that both illness and healing are God s will, sublimated the value of modesty. The belief that a physician was only a means and the real healer is God, the Creator, and without his generosity no cure could be achieved, fostered modesty as a valuable virtue. Many Ottoman Turkish medical writers adviced physicians not to be proud and not to over trust themselves. Physicians were perceived to be impotent like everybody, as physicians, whether able or unable, all passed away. While a physician was sublimated as a caliph of the Creator, being reminded that the real healer is Allah - God the Creator himself, pride was disapproved. Authorative behavior was not suitable for medical practitioners. 10 Several examples of the perspective, physician assuming to have cured patient must not boast, are found in Ottoman medical literature. Within the same perspective, Nidâî, a physician of the 16th century, advices his colleagues as described in the following couplet: Consider what awarded to you by God Always keep (your) inefficiency in mind. Nidâî describes in verse the failure of the physician assuming to have cured a patient: Don t say I have cured a patient This assumption is a real lie Both suffering and remedy is emerged by the Creator He does whatever he wishes; it is his, the Creator s will. 6 According to Emir Çelebi, another physician of the 16th century, Physician conceiving himself to be humble, should not relate the effects of treatment with his knowledge and skill. He should not conceive himself to be able; should not be proud of his art and practice; whatever may take place he must believe that God s favor will always be helpful. He must not behave proudly at the side of patient; he must even try to please and console patient. Emir Çelebi believes that a physician should also be dignified. 3 The meaning of modesty reflected other aspects of a physician s behavior, as well. Modesty was noted useful with respect to the development of medicine, as an attitude of a physician questioning himself/herself, too. For example, Abbas Vesim, a physician of the 18th century, deals with modesty with respect to a physician s consultation to his colleagues, valued as a favorable attitude in medical practice: Physician should travel from one country to another and should get in touch with those who were informed enough to discuss and present information about drugs and medical compositions; and should inquire and learn how drugs effect the body; should not pride with his ability; should not miss even a single word to be learned. For, facts and real knowledge are ideas and affirmations spoken by virtuous man. 1 Contentedness Higly Valued Virtues Justice and the right of equality in medical treatment was an important ethical norm and the value of justice fostered contentedness as a preeminent virtue expected from medical practitioners. 25, 26 The assumption that an ambitious physician eager to make money and own goods may drive him/her away from observing justice and truthfulness, consequently patients 3

17 Nil Sarı would not only be harmed, but trust in physician and medicine would be lost, is recorded in Ottoman Turkish medical manuscripts. 10 The developing function of the virtue of compassion by observing the virtue of contentedness can be noted in medical manuscripts, too. Perceiving a physician as compassionate meant that people trusted him as well. Şerafeddin Sabuncuoğlu, a surgeon of the 15th century, advices not to treat illnesses difficult to operate, in aiming to gain money: Do not try to operate a patient hopeless to be healed. While you are regarded as virtuous, beware being perceived as vulgar, being fond of gaining money. Act so that your mercifulness will overweigh your respectability and ambition. 8 Nidaî describes his evaluation of the expectation from a physician to contend with the reward paid to him in verse: Don t be fond of money, be satisfied with what you have a right to Do not be fond of this temporary existence Be careful to observe your destiny Behave truthfully, so that you will not be distressed. 6 Abbas Vesim relates that a physician must be contended with what he/she has a right to get, that is, the sum of what is spent in treatment, the drugs used and the fee mentioned. Abbas Vesim advices physicians to be contented, not to be ambitious and zealous for making money. The following words of Abbas Vesim describe clearly the real aim and function of medical practice: 1 The meaning of physicians being unambitious means the ambition for obtaining estates and gaining money, not willingness to cure the patient and the poor. Because, ambition for property and money lowers respect for the physician and trust for his treatment. 1 Fidelity Fidelity also being a highly valued virtue, a physician who started treating a patient was expected to continue his treatment so long as he can. A physician was expected to continue his treatment in spite of patient s improper behaviour disturbing him. It was an ethical rule for physician not to seize treatment, abandoning a patient untimely. 10 This rule was imposed as a responsibility to the physician. Abbas Vesim describes the rules of fidelity as: Physician must bare the misbehaviour of his patients. Physician should not retaliate his patient, even if patient behaved impolitely. Physician should ignore patient s rude acts. Physician should not react to patient s improper behaviour, on the contrary he should act within the framework of medicine and his skill, that is he should not incline to stop treatment, not feel offended, but try to continue treatment. Patience of an efficient physician is a way of treatment Patient s function is always to cause pain. 1 In return, the patient was expected to be responsible for experiencing the prescribed medicine and way of treatment. The patient was expected to act in accordance with the physi- 4

18 cian s advices for treatment, both for the patient s and physician s beneficence. Disregarding the physician s advices might be harmful both for physician and patient. This mutual responsibility is described by Siyahi, a physician of the 16th century: Some patients partly practice physician s suggestions, consequently may not be cured, for which physician is blamed. Do not commit a sin by meddling with physician s work. 7 Abbas Vesim advices physicians not to approach a patient disregarding a physician s advices, as did Siyahi. In such a situation, observance of the fidelity rule by the physician can be disregarded. In case a patient neglects to observe the physician s advices, the rule of fidelity can be ignored by the physician. Physician s right to leave a patient who doesn t observe his/her advices is defended and justified by Abbas Vesim, because, in such a case the patient may be harmed, consequently trust in the physician may be lost. If a patient hesitates to take the medicine adviced by the physician, or refuses to observe the physician s advice or speaks with the physician so as to get physician misunderstand him, the physician must end his relation with the patient. For, this is sure to cause a mistake. This approach is commented by Abbas Vesim. He writes that, if a patient distorts the physician s advice of treatment, being effected by advices of those inefficient in medicine and changes the treatment prescribed by his/her physician by the words of people who come and go; or not trusting the physician s advices based on the rules of medicine and acting on his own will, this act being against the law of medicine, mistake is inevitable. This fault is sure to be imposed upon the physician who treated the patient. For this reason, avoiding the treatment of such a patient can be justified. Otherwise, a physician s practice and advice will be comprehended/conceived as if he had not performed what he really did, and as if he had performed what he really didn t; and what he says will be conceived in the same way. In short, the patient was expected to cooperate with his/her physician and in return physician was expected not to desert his/her patient. Fidelity to a patient is in a sense derived from the importance paid to the value of hopefulness in treating a patient. 1 Hopefulness Higly Valued Virtues Physicians were expected to treat patients honestly, but not to express outrightly neither the patient s cure certainly, nor the hopelessness of curing or of nearing death. Cases in the past were used as analogies. As it was impossible to know of the patient s destiny certainly, the duty of the physician was to try to treat the patient until death. İbn Şerif, a physician of the 15th century, utilizing his own experience, justifies the importance of being wary in disclosing the fatality of patient to relatives: If a physician is asked, Is the patient going to die and when?, the physician must not inform the patient s relatives of his/her death; the physician must not say that the patient is going to die today or tomorrow. Not disclosing is beneficial, for we have come across many physicians who assumed that the patients treated and healed by us could not be cured and were going to die undoubtedly, they were not destined to die yet, so they recovered. We felt the pulses of many of them, it was a sign of death completely and prepared their shroud and dug their grave. However, they did not die, they recovered and got up. So, it is proper not to inform relatives and friends of a patient s death, even if the physician preconceives it. God alone knows the truth. Whatever the illness may be, the patient must be nicely treated. Perform whatever they 5

19 Nil Sarı are willing, and try to protect patients against disappointment. Patients must be kept away from sadness and anxiety whatever your way of treatment may be. Please some by motivating and by means of hopefulness and others by awarding presents. Rejoice others by having their close friends and kind hearted people visit them, so, patients will feel happy and their morale will be improved. 5 The physician was advised not to speak to the patient with certainty about the prognosis of his/her illness. Hacı Paşa, a physician of the 15th century, puts forth the rule: It is not proper to express outrightly that the patient is certainly going to die or be healed. 4 Abbas Vesim puts forth similar rules: A physician should not say that a patient is sure to go on living. Beware noting a certain period about the duration of patient s illness. 1 It was regarded an ethical rule for a physician to go on with treatment even with the hopeless patient, that is, never to give up treatment. Even if recorded in medical books that no medicine will cure an illness, it was believed that one should not seize hoping of God s mercy. A patient or a wounded could be cured miraculously, though not expected. Patients should be informed and warned of the harmful consequences of ending treatment. Some physician writers pushed this attitude even further, defending the idea that a patient must not be informed of the disappointing prognosis, thus hopefulness for treatment and the will of patient for going on to live should not be ceased. Not to grow hopeless of being cured, going on to be hopeful of the Creator s mercy and the body s potentiality of getting healed itself was highly valued. 10 Ahmed b. Bali s advices to physicians reflects this attitude: Encourage patient raising his/her morale by telling him that he/she is going to recover soon ; Do away with patient s troubles, supporting him/her willingly. 2 The Ottoman Turkish physician practicing Hippocratic, Galenic and Islamic medicine regarded himself as an assistant of nature and its power to heal. This was the main approach to the different prognosis in observing patients treated in the same diagnosis and indication. Discussion on Contemporary Medical Ethics Contemporary medicine has developed fast along with the development in technology and physician utilizing technology shared its miraculous products. Today, the human body and its various functions are observed and noted by means of developed diagnostic methods, technological instruments and laboratory tests. As physicians got to know more and more about the secrets of human biology and depend highly on technology, he/she intervened increasingly to the human body. Expectations from the scientific development of medicine influenced cultural and social views, too. Consequently, traditional ideas of health and life transformed, more or less, all over the world. However, as societies moral values differ from one another, proper argument of ethical issues in the developing medical field necessitates complementary knowledge, such as patients culture. Embodied in a particular society, each patient and family shapes and thus reflects the way he/she understands moral problems and what she/he takes to be feasible responses. Traditions and historical backgrounds of societies have to be valued to reach a better understanding of their contemporary morality. 6

20 As quoted shortly above, Turkish medical ethics in history relied on a virtuous behaviour expected from a health practitioner. Health practitioners were required to have a virtuous character for employment in Ottoman hospitals. 25 This may be the reason why today real informed consent from patient is far from being practiced in Turkey, patients relying on a physician known to be virtuous and efficient. A virtuous physician is expected to protect the patient from being harmed from a medical intervention and act fairly. 26, 29 However, paradoxically, written consent from patient before treatment has always been a requisite of law, both in Turkish history and today. 10 This subject is mainly a discussion of autonomy and paternalism. In this article, however, I would like to discuss another point of view. Today we contemplate highly on the transformations in our moral views resulting from new medical technologies and methods of treatment and their consequences. However, we do not evaluate historical material by utilizing the hundreds of year s experience of man as a field for learning. Study of ethics in the history of medicine has the potentiality of guiding us to moral attitudes and behaviours to be benefited from. I would like to start the discussion on the importance of past experiences, accumulated and developed through an evaluation of many case consequences over a long period of time. Although the above mentioned Ottoman Turkish moral concepts and values are those of a period when scientific medicine was not developed and theology played a great part in the attitudes and behaviours of medical practitioners, they are reflections of ethical behaviour expected to be practiced in medicine, based on hundreds of years of experience. The above mentioned values, virtues and rules of ethics depend on empirical information on morality, collected in a long period of history, which includes valuable information and subjects to be contemplated and discussed. Modesty Higly Valued Virtues It is known from antique times to today that a physician has opportunity of being authoritative. In the Ottoman period, the belief that the Creator is the real healer prevented a physician s authoritative attitude. Ottoman physicians, being astonished by the medical facts unveiling the amazing secrets of nature, were inclined to react modestly. 26, 29 Modesty as a virtue had the potentiality of preventing an Ottoman health practitioner from acting authoritatively. (Not telling the truth about a patient s nearing death was not regarded as an authoritative act, but a virtuous behaviour). 10 Innovations by intellectuals provided higher ability for the contemporary physician. This increase of ability provided opportunity for some physicians to conceive themselves as an authority on patients. Consequences of medical technology created an amazing feeling of achievement and this caused a potentiality of overflowing self-confidence in several medical practitioners. Medical technology provides great ability, but without it a contemporary physician could have been no more successful then the physician in history. Modern physician s efficiency would decline greatly without contemporary technology and pharmaceutical products. Without the tools contemporary physicians are bound to be in a worse position than the physician practicing medicine before the era of modern technology. This is reflected today in the reactions of newly graduated Turkish physicians appointed for compulsory service, who claim that they could not practice in rural districts with insufficient technological equipment. Modern physicians are not trained enough to utilize their five senses in physical examination for diag- 7

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