Medical Ethics in Libya; doctors are urged to develop a “culture of evaluation and monitoring”

To the Editor: In his outstanding editorial on medical ethics in Libya, Dr Elmahdi Elkhammas has raised awareness and promoted debate on this important issue. I have recently read the editorial and the forwarded comments in the correspondence and have appreciated its content [1–5]. I wish to add my thoughts to this debate.

The practice of medicine today is marked by strictly defined criteria and physicians are required to observe a strict code of practice. Doctors are expected to be able to preserve the trust of their patients. They are responsible for safeguarding, morally and intellectually, a high standard of conduct. Lack of professional and ethical behavior, as well as various economic, commercial, administrative, and environmental pressures, may aggressively interfere and erode this pact of trust. It can breach the working relationship. The rapid advances in medical knowledge and technology and the ever increasing expectations of patients have undoubtedly exasperated the doctor-patient relationship. This has revolutionized the practice of medicine. The health system has become very complex. Newly constructed hospitals often purchase the latest, most expensive equiment without a balanced investment in human resources. This is now regarded as ineffective. It may give only a false impression of modernization. A successful system should be capable of meeting design objectives, be able to measure its quality, identify the proportion of its failures and recognize its contributory factors, and have an accountability system. Efficiency in decision making and actions to be taken to meet the required standards are vital for the system to move forward.

Unethical behavior in general can be attributed to lack of personal attributes. However, occasionally it is a product of background and living conditions. A minority of individuals (not only doctors) in any given society often believe that principles of honesty, dignity and professionalism are not pertinent to meet their living expectations and satisfaction. These individuals do not hesitate to reject moral obligations to achieve their objectives. They often feel superior and consider themselves smart and opportunistic. The reported widespread lack of professional values and behavior in the daily practice of medical doctors in Libya is alarming and of concern. Although it is difficult to estimate its impact, the real phenomenon, and which category of doctors tends to be more likely to be affected, remains unclear. I regard this to be an important point. It has potential to be expanded and eventually clarified.

Although this may only partially explain the quality of care provided over the years by many honest Libyan colleagues, it reminds us that we are encouraged to look and learn from the practice of others, to consider and assess also our own experiences, praise achievements, and learn from failures.

Single individuals and authorities involved in health services are now pressured to be more effective in the fight against infringement of rules and regulations in order to secure a safe working environment and good patient care. Recommendations and guidelines governing the principles of good medical practice are now widely available. They can be easily adapted to the specific working environment. Successful implementation will require stronger interpretation of justice and security in the working environment, as well as keen insight into the role and mission of individuals. Taken from this point of view, implementation of rigid rules may be difficult to achieve. The mechanisms put in place to see how effectively and to what extent the policies have been implemented may remain a set of well-meaning aspirations. In addition, if the objective is to find competent, independent, and expert people to be responsible for implementing with transparency and without conflict of interest, then the mission becomes (nearly) impossible!

I personally believe that virtually nothing in practice has been done in this direction in our profession in Libya. There is a pressing need to approach these issues, knowing in advance that compliance with the strict rules and regulations will depend on our ability to recruit and develop a work force conscious of its role and capable of responding to its obligations.

Let us at this stage go forward in a positive tone, consider the merits of our professionals not only inside the country but abroad, and be willing and prepared to deploy efforts to improve and develop a “culture of evaluation and monitoring” in our activity which, if coupled with self consciousness and responsibility, will drive effective change towards a “culture of cure and care”.