BMJ  2005;331:230 (23 July), doi:10.1136/bmj.331.7510.230

Commentary

Ethics in health care and research in European transition countries: reality and future prospects

¹ Croatian Medical Journal, alata 3, HR-10000 Zagreb, Croatia marusica{at}mef.hr

Boroveki et al examined the structure and performance of hospital ethics committees in Croatia, as a paradigm of healthcare ethical regulations in transitional countries.¹ They found out that these bodies were highly bureaucratic and concerned almost exclusively with approval of research protocols, and that their members were mostly older physicians without the knowledge and skills that would be useful for the other functions of the ethics committees (education, guidelines development and ethical case analysis).

The same legalistic and bureaucratic organisation is a characteristic of the whole legal regulation of health care and health professionals in a transitional country such as Croatia.² It is thus not surprising that ethical regulations are taken lightly and that their breach is common. For example, cheating, as an example of unethical behaviour, is very common among medical students in Croatia.³ A study of attitudes towards cheating, involving economics students in Russia, Israel, the Netherlands, and the United States, showed good correspondence between students' perception of cheating and corruption in the society.⁴ In contrast with the United States and many Western countries, where cheating is considered unfair competition and is condemned, in former communist countries the governmental system was always a servant of the party and thus considered an enemy by most citizens. High cheating rates among students and their permissiveness towards cheating, as well as a lax approach to ethical norms in general, can be explained by socioeconomic laws: the less consistently a norm is observed in a society, the lower the cost incurred by an individual deviating from the norm.⁴ The universities and healthcare institutions alike have a set of norms which are similar to those in most developed democracies, but they are usually buried in the legal departments (and now in the intranet pages) of the schools and institutions, and there is little education or institutional enforcement of adherence to the norms. Even analysis into the system and quality assessment is often not welcome: when we published the results of our study on academic misbehaviour of medical students,³ some of our colleagues regarded it as "not a nice thing to say about our school."

So what can be done? Realistically, bureaucratic and dishonest behaviour cannot be completely eliminated before other sectors of the society improve. For countries joining the European Union, any change must come from within, as the countries that made up the "old" EU may not provide the best example. Bureaucratisation, the closed nature of academia, and self sustenance of academic communities are not restricted to small scientific communities in former communist countries. Favouritism or "inbreeding" at universities, defined as the percentage of teachers at a university who trained at the same university, is especially high in Portugal (91%), Spain (88%), Italy (78%), Austria (73%), and France (56%), compared with the UK (5%) and Germany (1%).⁵ What the EU can do for its new members or in negotiations with future members is to insist not only on high ethical standards in medicine but also on their implementation. Only education and transparent regulatory actions can improve the integrity of both present and future doctors and promote responsible and trustworthy physicians as leaders of changes in society.

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Competing interests: None declared.

References

1. Boroveki A, ten Have H, Orekovi S. Ethics and the structures of health care in the European countries in transition: hospital ethics committees in Croatia. BMJ 2005;331: 227-9.[Free Full Text]
2. Bonjak D, Marui A. Croatia: legal regulation of doctors. Lancet 2000;356: 1349-50.[CrossRef][Web of Science][Medline]
3. Hrabak M, Vujaklija A, Vodopivec I, Hren D, Marui M, Marui A. Academic misconduct among medical students in a transition country. Med Educ 2004,38: 276-85.[CrossRef][Web of Science][Medline]
4. Magnus JR, Polterovich VM, Danilov DL, Savvateev AV. Tolerance to cheating: an analysis across countries. J Econom Educ 2002;33: 125-35.
5. Soler M. How inbreeding affects productivity in Europe. Nature 2001;411: 132.[Web of Science][Medline]

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

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BMJ 2005 331: 227-229. [Extract] [Full Text] [PDF]

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