As the world turns slowly but surely into one large civil society, not to mention a global village, it would appear that all aspects of life, including healthcare, become increasingly liberal. This is particularly the case for those areas of expertise which are traditionally on the cutting edge of increased possibilities and cultural influences, such as Obstetrics and Gynaecology. Unfortunately these changes can often result in ambivalent feelings.
On the one hand this change in society has lead to huge increases in personal freedom, allowing individuals for the first time in history to become the very person they desire to be, pushing the boundaries of possibilities. Yet at the same time, professionals working in their respective fields of healthcare are therefore not only increasingly confronted with their own professional value-systems, but also with the boundary-pushed value-systems of their patients. Add to this the invisible hand of market-forces, as well as cultural diversity, and doctors may experience ethical dilemmas, which in turn may lead to tensions. For example, is a colleague who performs labium corrections without medical indication a bad doctor, or indeed is he or she a respectable businessperson? Furthermore, when can one speak of genital mutilation and when can one speak of personal freedom, either in a cultural or religious context?
Many healthcare professionals experience an ethical and mental discomfort-zone on this subject. On the one hand one wishes to fully respect the integrity and emancipation of women in general, but equally one does not want to diminish or disrespect the traditional or new-age culture of others.
Chen et al. (in this issue) show how routine actions of a gynaecologist, such as performing a gynaecological examination, are very much influenced by local cultural norms. In addition, verbal communication between doctor and patient are also not necessarily without anxiety, as some words can be misconstrued as sexually tinted, and may therefore be perceived as crossing an invisible line of appropriate behaviour.
In essence, professionals are at all times expected to act and behave ‘correctly’ according to their professional standing. However, that correct behaviour is prone to being perceived subjectively; subject to personal interpretation by both doctors themselves, as well as their patient's interpretations. Many professionals have been caught up and caught out by this ethical dilemma of ‘what is right and what is wrong’.
As a result there have been health-professionals demanding outright clarity, by wishing for iron rules such as government guidelines, since being without them may result in professional vulnerability.
However, the cry for hard and fast rules on traditional and new-age cultures and whether gynaecological operations should or should not be performed, does not offer a scot-free answer to the problem. For every health-professional who does not wish to be lead by market-forces nor by ancient cultural heritage (and not by government rules either) there is another directive force that can be adhered to: The powerful force of professional honour.
The reciprocity of social appreciation, to and from significant colleagues in their respective fields of expertise, is a most powerful instrument. Indeed, the values and norms that we wish to pass forward to our medical students make a direct appeal to their sense of honour. Evidence shows that this type of grading works very effectively. Even without explicit education on this subject, students quickly identify with the interpersonal aspect of receiving professional honour, which further stimulates their own ethical and honour awareness.
The obvious downside of honour as a steering-mechanism is that feelings of honour are not tangible and hence not quantifiable, unlike services or goods. A true sense of honour can only be born from purity in behaviour and genuine heartfelt interactions. Therefore, the key-ingredient of appreciation and honour consists of the value of authenticity, and hence falls into the category of value-goods, not unlike love and affection.
Honour can not be bought, nor can it be requested nor demanded, for it has to be earned, through actions and interactions. It is therefore subject to the teleological paradox: ‘It is a highly effective tool provided it is not used specifically for its own sake’.
It would appear that there is only one way to escape this paradox, which fortunately also allows for the increasing demand for professional transparency. Hence the answer lies in publishing articles and presenting them to colleagues around the world, specifying what is considered the ‘right’ thing to do according to newly pushed boundaries, norms and local contexts.
For only when professionals enter the debate about ‘the correct thing to’, and develop strong theoretical and practical arguments on weighing the pro's and con's, and how to arrive at decisions, can new and groundbreaking insights continue to be achieved.
It is therefore to our delight that we present you this JPOG December issue, which offers a range of highly idiosyncratic articles, warmly inviting you to partake in this particular discussion.