Stjepan Orešković

Ethics and the structures of health care in the European countries in transition: hospital ethics committees in Croatia

Hospital ethics committees are a recent phenomenon in countries in transition. Croatias example shows they are staffed mainly by older doctors with no specialist knowledge of ethical issues. The importance of professional relationships and the educational function of ethics committees have been ignored

Education of ethics committee members: experiences from Croatia

Objectives: To study knowledge and attitudes of hospital ethics committee members at the first workshop for ethics committees in Croatia. Design: Before/after cross-sectional study using a self administered questionnaire. Setting: Educational workshop for members of hospital ethics committees, Zagreb, 2003. Main outcome measurements: Knowledge and attitudes of participants before and after the workshop; everyday functioning of hospital ethics committees. Results: The majority of the respondents came from committees with at least five members. The majority of ethics committees were appointed by the governing bodies of their hospitals. Most committees were founded after the implementation of the law on health protection in 1997. Membership structure (three physicians and two members from other fields) and functions were established on the basis of that law. Analysis of research protocols was the main part of their work. Other important functions—education, case analysis, guidelines formation—were neglected. Members’ level of knowledge was not sufficient for the complicated tasks they were supposed to perform. However, it was significantly higher after the workshop. Most respondents felt their knowledge should be improved by additional education. Their views on certain issues and bioethical dilemmas displayed a high level of paternalism and over protectiveness, which did not change after the workshop. Conclusions: The committees developed according to bureaucratic requirements. Furthermore, there are concerns about members’ knowledge levels. More efforts need to be made to use education to improve the quality of the work. Additional research is necessary to explore ethics committees’ work in Croatia especially in the hospital setting.

Developments regarding ethical issues in medicine in the Republic of Croatia.

In Croatia, the subject of medical ethics, or bioethics, was introduced into the curriculum in the early 1990s at the medical schools of the University of Rijeka and the University of Zagreb. Today, bioethics education has become a basic part of undergraduate medical education not only in Rijeka and Zagreb but also in Osijek.

Developing a Model of Healthcare Ethics Support in Croatia

Croatia is a transitional society in that it is a country emerging from a socialist command economy toward a market-based economy with ensuing structural changes of a social and political nature—some extending into the healthcare system. A legacy from our past is that, until now, Croatian healthcare institutions have had no real experience with clinical ethics support services. When clinical cases arise presenting complex ethical dilemmas in treatment options, the challenges presented to the medical team are substantial. The case described below recently occurred on a ward in a university hospital in Croatia. An unexpected request from the patient’s parents created a number of issues that needed to be addressed by the medical team, which was made more difficult by the lack of clinical ethics support services. Such cases press the question currently being debated as to what type of ethics support services would be suitable for Croatia and why.

Evidence-based bioethics: delineating the connections between science, practice, and values in medicine

The origins of bioethics, self-defined as “science of survival”, are diverse (1). They can be traced back to the Code of Hammurabi (1754 B.C.), which introduced specific rules and drastic penalties for physicians in the cases of therapeutic failure. Using a connection between responsibility for a medical intervention (rules 215-225) and measurable outcome, the Code represents an early attempt to establish strict behavioral guidelines: “If a physician make a large incision with the operating knife, and kill him, or open a tumor with the operating knife, and cut out the eye, his hands shall be cut off” (2). There is a significant difference between the evidence collected to make a value judgment for a particular case and the evidence that serves in the process of testing a certain hypothesis about the nature of things (3). The Judgment of Solomon represents the model and the case for a peculiar bioethical method and approach in a “life-or-death situation” decision-making. When King Solomon of Israel was called to make a judgment regarding two women who both claimed to be the mother of a child, he employed a wise and intuitive method. He was tricking the “mothers” into revealing their true feelings. From a bioethical point of view, his task was to distinguish the right outcome from the wrong outcome without any empirical evidence. The episode has become an example of a middle ground argument (argumentum ad temperantiam), where an impartial judge displays wisdom in making a decision. Solomon was collecting evidence with a non-standard, non-epidemiological method for informed decision making. The Case of Re A (Separation of Conjoined Twins and a decision of the Court of Appeal of England and Wales) likewise demonstrates the complexity of bioethical decision-making (4). The Hippocratic Oath (500 B.C.E.) marks the beginning of Western ethical reasoning and decision-making in medicine. However, the well-known phrase “primum non nocere” (first, do no harm), which became the binding ethical rule of the utmost importance is not in the Hippocratic Oath. It comes from The History of Epidemics, which is part of the Hippocratic corpus (5). The same applies to the well-known principles of non-maleficence and beneficence “salus aegroti suprema lex” (well-being of the patient is the most important law).

Hepatitis B and HIV/AIDS in Zagreb: A district level analysis

This study examines the presence of hepatitis B as a possible precursor marker for HIV/AIDS in 10 districts of Zagreb, Croatia. There were a total of 931 cases of hepatitis B in Zagreb in the period 1979–1995, the annual rate ranging from 3.1 to 15.4 per 10,000. The highest relative risk for hepatitis B for the 1979–1995 period was in the Pescenica district (Relative risk (RR): 1.4). There were 108 cases of HIV/AIDS diagnosed in Croatia in the period 1986–1996, with 34% from Zagreb. The highest relative risk for HIV/AIDS was within the Pescenica district (RR: 2.3). Pescenica had also a significantly higher incidence of hepatitis B when compared to other districts (p = 0.005). The cumulative incidence of hepatitis B in Zagreb was directly related to levels of neighborhood discomfort as determined by an index including unemployment, inflation and housing conditions (p = 0.005). This research demonstrates that the poor areas of the city with higher incidence of hepatitis B hold the greatest threat for the spread of HIV/AIDS.