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.1
Zurak N, Derezic D, Pavlekovic G.
Students' opinions on the medical ethics course in the medical
school curriculum. Journal of Medical Ethics
1999;25(1):61–2.
Today, bioethics education has become a
basic part of undergraduate medical education not only in Rijeka and
Zagreb but also in Osijek.
Even before the 1990s, however, efforts had been made to forward the
field of medical ethics in Croatia. Early examples were the creation of
a Center for Medical Ethics at the Andrija štampar School of
Public Health at the University of Zagreb Medical School in the 1980s
and the establishment of the annual workshop on human rights and
medicine at the Interuniversity Centre in Dubrovnik. To date, though,
there has been no development toward introducing postgraduate courses,
and there is still a lack of skilled professionals in this field,
although the number of scholars is growing.
Throughout central and southeast Europe, the situation varies, from
countries that have developed sound legal and educational
structures2
Yaskevich Y. Development of
bioethics in the Republic Belarus. In: Glasa J, ed. Ethics
Committees in Central and Eastern Europe. Bratislava, Slovakia:
CHARIS-IMEB; 2000:165–8.
to others where these do not
exist.
3 Payne J. Unterricht in
medizinischer Ethik in Tschechien. Ethik in der Medizin
1996;8(4):226–31.
Furthermore, the damaging effects on
health of recent wars, continuing unrest and conflict in the countries
in transition, and the economic hardships faced by their populations
have influenced the shifting societal frameworks and the transformation
of fundamental societal values and patterns of behavior where many
relationships, including those between physicians and patients, are
undergoing fundamental changes. Better education will reinforce a moral
commitment to patients' rights, equal access to healthcare,
quality of care, solidarity, and protection of vulnerable populations,
as well as promote general well-being. Developing ethics awareness in
particular will help to articulate the human values underlying all
healthcare activities.
The Andrija štampar School of Public Health has recognized the
importance of ethics education at all levels of the medical curriculum.
With support of the Council of Europe and its Social Cohesion
initiative as part of the Stability Pact for SEE,4
Marusic A. Health ministers of South East Europe agree to
cooperate to improve health. Lancet 2001;358:902.
the
school initiated the new Master's program for Health, Human
Rights, and Ethics, which aims to improve ethics education at both the
postgraduate and undergraduate levels. This project is part of a loan
from the Council of Europe Bank of Development to aid curriculum
development and reconstruction of the school. The project has also been
supported by the WHO and the SEE Public Health Network.
Ethics Committees
European countries have seen different levels of progress regarding
the institutionalization of bioethics and the development of ethics
committees. In particular, the development of research ethics
committees has been more pronounced—almost all countries have
legal provisions and research ethics committees mandated by law.5
Tschudin V. European experiences of ethics
committees. Nursing Ethics 2001;8(2):142–51.
The status of clinical ethics committees, however, varies with regard
to approach, organization, and legal foundation.
6 Lebeer G, ed. Ethical Function in Hospital Ethics
Committees. Amsterdam: IOS Press; 2002:9–124.
The
process of institutionalization of bioethics is regarded by some as
especially important to those European societies in transition. In
particular, development of clinical and healthcare ethics committees
could encourage the growth of professional bioethics and the creation
of important networks.
7 Gefenas E. Is
“failure to thrive” syndrome relevant to Lithuanian
healthcare ethics committees? HEC Forum
2001;13(4):381–92.
However, such institutionalization,
if not carefully thought through within a specific context, can
generate skepticism and bureaucracy.
8 Siegler M. Ethics committees: decisions by bureaucracy.
Hastings Center Report 1986:16(3):22–4.
In Croatia, the first steps toward bioethics institutionalization
through ethics committees began in the 1970s with the creation of what
were referred to as the “commissions for drugs,” which were
established for the purpose of joint Croatian-international clinical
research projects. In the 1990s, ethics committees became required by
law, with articles 51 and 52 of the 1997 Law on Health Protection
devoted to setting the framework for their duties. According to this
law, each healthcare institution in Croatia should have an ethics
committee consisting of five members, two of whom should be from
outside the medical field. Committee functions include:
- following the implementation of ethical principles of the medical
profession
- approving research activities (protocols) within the health
institution
- overseeing drug and medical device trials
- overseeing organ procurement, and
- solving other ethical issues in the health institution.
In 2001, the National Bioethics Committee for Medicine of the
Government of the Republic of Croatia was founded. This independent
advisory and multidisciplinary body is involved in policymaking,
education, and debates on ethical issues on the national level. It has
20 members, seven of whom are women, representing a variety of
specialties: hematology, internal medicine, clinical and basic
pharmacology, epidemiology, public health, gynecology, history of
medicine, gastroenterology, basic medical sciences, and genetics. There
is also a veterinarian, a biologist, a molecular biologist, a
philosopher, an experimental psychologist, and a Catholic moral
theologian. The committee acknowledges and inculcates in its work the
values expressed in numerous international declarations and
documents.
In 2002, the National Bioethics Committee conducted research on the
functioning of Croatian ethics committees. Of particular interest were
the number of members, structure of membership, themes discussed during
meetings, reports drafted on the work of the committees, number of
meetings to date, policies, and guidelines. Excluding pharmacies and
homecare institutions, 241 healthcare institutions took part in the
study. Of the participating healthcare institutions, 111 reported
having an ethics committee. Of four medical faculties in Croatia, three
have an ethics committee. There are also ethics committees at the
Faculty of Veterinary Medicine and the Faculty of Pharmacy and
Biochemistry in Zagreb, at the Institute for Anthropology, Institute
for Medical Research, Institute Rudjer Bošković, and at
the Croatian Medical Chamber and Croatian Medical Association, Croatian
Dentists' Chamber, Croatian Pharmacists' Chamber, and
Croatian Chamber of Biochemists. The response rate was between 100% and
75%, depending on the type of the institution (100% response rate for
clinical hospitals, 91% for regional and local general hospitals, 80%
for clinics and policlinics, 75% for medical faculties, and
approximately 77% for all other healthcare institutions, including
public health institutes, primary care facilities, and ER facilities.
Ethics committees tend to have from five members as required by law to
ten (though two did not state the number of members, four have only
three members, and two have four members).
All of the committees have physicians as members, and 34 committees
include a nurse. Only one committee had a philosopher.
Almost all committees stated that reviewing research protocols was
their main task, though some deal with other issues as well, mainly
concerning “the promotion of the ethical values in their
institutions.” In 19 institutions, a “commission for
drugs” also reviews clinical protocols, which creates additional
confusion about the tasks of ethic committees. Other committees, such
as those of the Croatian Medical Chamber and Croatian Medical
Association, the Croatian Dentists' Chamber, the Croatian
Pharmacists' Chamber, and the Croatian Chamber of Biochemists,
deal primarily with deontological values and issues of the specific
professions they represent and do not function in a research oversight
capacity. Of all institutions involved in this research we received
only 22 procedural guidelines for the conduct of meetings. Only in
three cases were international documents and declarations cited (e.g.,
the Helsinki Declaration, Tokyo Declaration, Guideline for Good
Clinical Practice). Other documents cited included the Ethical Codex of
the Croatian Medical Association, the law on the protection of the
mentally ill, the law on healthcare protection, and the law on health
insurance.
Recently, the National Bioethics Committee proposed changes to the
existing legal provisions for ethical committees—in particular, a
division was proposed between ethics committees, which now by law
perform both tasks of research ethics committees and institutional
review boards, and clinical ethics committees. According to this
proposal, the functions of the research ethics committees and clinical
ethics committees would be split. The research ethics committees would
be in charge of the review of research protocols. They would be
organized on the regional level according to the European guidelines
and would have legal responsibility for their decisions. Clinical
ethics committees would be organized locally or regionally, depending
on the type and needs of individual healthcare institutions, and would
address three tasks: education, policymaking, and clinical case
consultations. Unfortunately, this proposal was not accepted by
governmental bodies.
Other Ethical Issues and Developments
A number of new healthcare laws have been established or are being
drafted in the Republic of Croatia—for example, the recently
drafted Law on Patients' Rights. The Convention on Human Rights
and Biomedicine of the Council of Europe together with the additional
protocol on cloning as well as the new law on drugs are due to pass
Parliament by the end of 2003.
However, some remaining issues have been a continuing source of legal
and ethical problems. Croatia has no law on artificial insemination,
for example. There was an initiative by the National Bioethics
Committee to begin drafting a law to regulate this field, but for a
variety of administrative and political reasons this process has not
come very far. Hopefully, in the future there will be some improvements
in this area.
In conclusion, one could say that developments regarding ethics
issues in medicine have gone far in Croatia, but a lot of work remains
to be done, especially on the educational and legal levels.
