Introduction:
Ethics deal with right conduct by members of civilized society in all the walks of life. So, every profession has ethical code which needs to be followed by its members. Ethical code is different from legislation.  Actually, code does away with the need for legislation as it secures orderliness in the lives of people. Ideally the rights, duties, and actions of individuals, as members of the society, come within the preview of ethics. Medical ethics is part of the general ethics, derived from values in medical profession. It includes obligations of doctors to patients, doctors to other doctors, other health providers, learners to trainers, trainers to learners, managers of medical profession, and the society as a whole. Medicine presupposes certain fundamental values like, preservation of life, relief of sufferings, cure of diseases, prevention of diseases and promotion of health. Ethics in health profession is a fundamental multi-faceted issue for the members of the society because health is essential for the wellbeing of everyone in society. The ways in which people are trained for health care bears importantly on the health of society.

Objective:

To get information about the status and challenges related to ethics in health professional’s education and health care in modern days. 

 Methods:
Keeping in mind the objectives, literature search of the studies and, reviews about HPE and health care was done by various available search engines. There was no special inclusion or exclusion criteria for studies and reviews. Whatever could be accessed was looked into. Available local, national, and international opinions and self-observations were also added.

Results: 
Ethical challenges are visible in medical profession, from beginning to end of life, be it HPE, or health, care be it issues of doctor - patient relationship, and doctor - public relationship. Malpractices, negligence in health care, irrational and unethical promotion of drugs, lack of autonomy of patients, social injustice and inequity in health care. Visible commercialization of HPE with malafide intentions seems to be the tip of the iceberg. There are two major aspects which need critical relook, ethics in HPE and ethics in health care.

Ethics in Health Professionals’ Education:

There are some visible issues in relation to ethics in HPE. Admission of health professionals to training / learning institutes, for undergraduate, postgraduate training as well as evaluation seem to go on in unethical ways, with mostly commerce in mind. Medical education differs from other study programs, as it offers restricted choices and uses few teaching formats like didactic teaching, problem-based learning, bedside clinical teaching [1,2]. In addition, students live with distress and dilemmas as they see and hear about everyday happenings around them. Over the years several studies have shown that majority of the medical students believed that ethical practices were critically important in the provision of the high standards of medical care. Janakiram [3] reported that conventional medical training does not really help students in resolving the ethical dilemmas they face as they get admitted, they learn and get evaluated. Allmahmoud [4] also reported that little is known about the ethical dilemmas medical students encounter while learning health care, which creates distress and trauma. Research has revealed that medical and dental postgraduates had obtained their knowledge of bioethics from internet, newspapers and with their own observations at workplaces. Over decades students have expressed enthusiasm to learn about medical ethics [5,6]. Medical students view ethics positively and prefer clinically attuned methods about learning of ethics [7]. Godbold [8] reported that despite a clear mandate to educators, there are differing approaches, in particular, how and where ethics is placed in training programs, underpinning philosophies and optimal modes of assessment. Furthermore, ethical curricula were being structured in relation to bioethical principles rather than consideration of trainee’s experiences, and their self-identified educational needs. If future physicians have to be properly trained for solving public health and societal health problem in ethical way, they need to learn social entrepreneurship during their education.

Ethics in Health Care:

There are many ethical challenges in health care which impact not only patients and families but health providers too. To begin with informed consent which in recent times has become a matter of defense rather than truly informed consent because of various reasons, especially because doctor patient trust is lost. While it is essential to inform and take consent, it is also important not to use it as a defense. Concern for the patient needs to be of utmost importance. Overuse of sophisticated expensive technology, for financial gains is highly unethical but continues everywhere. Pandit et al [9] opined that a patient approaching a doctor expects medical treatment with all the knowledge and skill that the doctor can possess to bring relief to patient’s health problem.  A doctor has duties to his/her patient and breach of any of the duties gives a cause for action for negligence against the doctor.

Clinical Trials:

Clinical trials and human experimentation are essential and so are common in health care. Nardini [10] reported that over the years results of randomized controlled trials (RCTS) have prevailed over clinical judgment, case reports, and observational studies. They have become the evidential gold standard in medicine. As clinical research is progressing, the ethics in clinical trials are becoming increasingly complex because research questions are becoming more complex. The ethical discourse has to keep abreast of the change, in order to provide an adequate guidance for medical research. Clinical trials needed to be tightly regulated enterprises which must comply with ethical requirements while maintaining high epistemic standards. The doctor is bound by professional ethics to do all that is in his /her power to benefit current patient, to forward medical science for the benefit of future patients. The necessity of a framework for critically discussing and evaluating human experimentations arises because the present tools of medical ethics alone are insufficient to direct the course of action when facing dilemmas. Clinical trials need proper information to study subjects about advantages to them and to the society. Results of any trials, positive or negative must be known to the world. They need to benefit patients, present and/or the future. Even negative results help.  Essential prerequisites for trial need to be ensured. They include informed consent, confidentiality, accountability, responsibility, transparency, risk minimization and compensation. Institutional review boards needed to ensure publication of the results which have to be authentic, without any pressures. Many ethical aspects continue to be overlooked in clinical trials and results. Study subjects could be children, pregnant women, elderly and others who have special needs. Safety of drugs, vaccines, the right dosage, and route of administration must be ensured in trials with special precautions in such situations, International code of medical ethics declares that, any therapy which could weaken physical or mental resistance of human beings  may be used only in patients interest. Regulations are must to prevent harmful effects. Storeng [11] reported that a donor commissioning a research for evaluation of one of its major global health programmes must not instruct the researchers to omit important findings from their final report or to change the conclusions. Staff of an implementing partner must never threaten the reputation of the researchers and their university on publication of negative findings. Creation of infrastructure for research must be in cooperation among academia, government, the pharmaceutical industry and active patient community.  Alexander [12] reported that the experience of the past decade has shown that for patients’ safety small efforts will not be adequate. Clinicians must work towards transformative change to integrate research and practice accountability, responsibility and transparency in trials with risk minimization.

 Ethics in Organ Transplantation:

Organ or tissue donations may be for research, but very often, healthy transplantable organs and tissues are donated for transplantation   into another person [13]. Organ donations are essential and are saving lives. Organ donations from living persons, from cadavers, help human survival but exploitation of the poor to part with their organs for the rich, particularly kidneys, continues unabated, in criminal ways more because of high numbers needed and low numbers available.   Wikipedia [14] reported that in Robin Cook’s novel ‘Coma’, set in the present day, the organ thieves operated in hospitals removing the organs from patients who needed long-term care. The organ donations from criminals is getting institutionalized within society to the point where even minor crimes are punished by death, in order to ensure the supply of organs. The state-sanctioned involuntary organ transplants are one step in the concept of creating people solely for the purpose of acting as organ donors. Generally, these donors are clones of their eventual organ recipients.

Ethics of Long-Term Therapies and Euthanasia:

When a patient is terminally ill, there are differences of opinions among health professionals about informing the patient, whether to  keep the patient in the hospice, give tender loving care or help him/her die peacefully, ‘Euthanasia’ the will to die needs further discussions [15] . There are many moral issues that arise. The inherent relationship between the health care profession and euthanasia are contractdictory.  Legalizing euthanasia or assisted suicide involves many, physicians, scholars in ethics, health laws, politicians, and the general public. Both proponents and opponents of legalizing euthanasia need to look into the wider consequences that legalizing euthanasia might have on the medical profession, the institutions of law and medicine, and society as a whole. The risk and harms of legalizing euthanasia seem to outweigh the benefits. Ethical alternatives to euthanasia are needed as it is incompatible with physician’s primary mandate of healing. It actually contradicts the mandate. The line of argument that connects this narrative and supports the rejection of euthanasia is ‘intentionally inflicting death on anybody by health providers is inherently wrong’. But Boudreau [16] reported that legalization of Euthanna in the Netherlands, Belgium and Lichtenstein, subject to certain conditions, was a testimony of change in the society.

Ethics in Reproductive Health Care:

Assisted reproductive technologies or surrogacy are needed for a small number of couples who have infertility and want to have their own child but cannot. ART are justified only when natural conception is not possible, but ART and surrogacy have become businesses.  Induced abortion has existed since time immorial at to ensure justice to women, but controversies still continue globally. Those against abortion talk of right. Prenatal diagnostic techniques, Regulation and Prevention of Misuse Act 1994 became the law of country in India in 1996 [17]. It was for preimplantation genetic diagnosis for the benefit to society, but is being used for sex selection, which is illegal, immoral and unethical. Sex-preselection, female feticides, infanticide are crimes but go on in many regions. Women are demeaned. However, there is another aspect.  There are many couples who have a son and want a daughter, whether sex selection, is ethical/ becomes a question. There are two groups that occupy the primary places of the preconception sex selection debate, one is the. American Society of Reproductive Medicine (ASRM) in the United States and the other is the Human Fertilization and Embryology Act (HFEA) of 1990 in UK. HFEA banned sex selection for social reasons after majority of respondents to a consultation exercise felt that sex selection should not be available for family balancing. There is potential for inherent gender discrimination, inappropriate control over nonessential characteristics of children [18].

Distribution of Resources:

In the attempts to have distributive justice in health care, Article 39(e) of constitution of India required that the health and strength of workers, men, and women and the children were not abused and that citizens were not forced by economic necessity to enter vocation unsuited to their age or resources. Article 47of the constitution of India talked of ‘Obligation for the State to make improvements in public health’. Article 38 of Indian constitution-imposed liability on state that ‘states will secure a social order for the promotion of welfare of the people’s health, they achieved it without welfare of people was impossible. Article 42 made provision to protect the health of infants and mothers by maternity benefits’ and Article 47considered that the primary duty of the state was to improve public health [19]. Social Justice and equity in health are essential for right to health. But essential health care is also beyond their reach.  Rather than distributive justice in health care, it is lack of primary care to poor and overuse of high tech for rich.

Malpractice and Negligence and Ethics: 

The classical aim of medical practice has always been to cure sometimes, to relieve often, to comfort always, but malpractices and negligence go on globally. Croke [20] reported that medical malpractice has been defined in professional literature as ‘any act or omission by a physician during treatment of a patient that deviated from accepted norms of practice in the medical community and caused injury to the patient’. The terms “malpractice” and “negligence” are sometimes used interchangeably. Negligence in healthcare is not doing what a reasonably prudent person would do in a similar situation. Negligence does not imply a professional relationship between the offending and injured parties although in healthcare, that relationship usually exists. Malpractice means that a licensed healthcare practitioner has failed to meet the standards of his /her profession in the treatment of a patient. Malpractice is violation of the laws of a professional discipline. Professional misconduct comes with improper or insufficient knowledge or skills or attitudinal problem or greed.  It may be defective application, because of lack of knowledge or skills or problems in attitude or malafide intentions. Prescribing right drugs, in right doses, at the right time, for right duration, and with right diagnosis are all essential. Pregnant or breastfeeding women, persons with diseases of liver and kidneys need special care [21].  But unethical negligence goes on. Doctors have a duty to deliver the care according to accepted standards for the problems after discussions with the patient. To fail in this regard is considered negligence. Croke²⁰ reported that during recent times, medical errors have been found to be the third leading cause of death in the United States. Somewhere between 200,000 and 400,000 patients suffered or died each year from causes that could have been prevented. For healthcare professionals staying ahead and avoiding negligence and malpractice required constant surveillance. Elliott [22] reported that in England, there were an estimated 237 million medication errors annually, half of which were administration errors, with minimal or no potential for clinical harm. WHO [23] reported that patients in low-income countries lose twice as many disability adjusted life years due to medication-related harm than those in high-income countries? It is not uncommon for health care professionals to clash with the family of the patients over treatment decisions. Some patients inevitably suffer the consequences of an error made during their care.

Others:

Breslin et al [24] have reported that there are challenges and the top challenge was disagreement between patients/families and health care professionals about treatment decisions. The second highest ranked challenge was waiting lists of patients. The third ranked challenge was access to needed resources for the aging and chronically ill. Further the academic entrepreneur must either license the technology or become more knowledgeable in commercializing their patented ideas. Researchers have said that as medicine moves further into the 21st century, lifesaving therapies will move from inception into medical products faster if there was a better synergy between science and business. Researchers also reported that Germany dominated international science as training center for scientists worldwide [25].  Researcher suggested that the synergy between education and business was appreciated in Europe, Asia and America. British science evolved to dominate the field of science during the prewar and post-world war because the German scientists fled Hitler’s regime. These expatriated scientists had a profound influence on the teaching and training of British scientists, which lead to advances in medicine. After the second world war, the US government funded the development of the medical infrastructure and British German scientists in medicine moved to America because of availability of funds.  Researchers have also said that the expatriated scientists helped drive the medical advances into commercialized products. America was always the center of medical education and advances of biotechnology. International scientists trained in America went to Europe and Asia as their governments were aware of commercial potential of biotechnology and were prepared to play active role in science and biotechnology. The legislations applied to all health-care professionals who prescribed, dispensed, recommended, supplied, or administered a drug. In France it applied to health professionals, and patient organizations, health publishing companies, and software companies [26]. In France, the Bertrand Law was enacted in 2014 report payments from industry and included cosmetics, health software, and therapeutic products with heavy fines for noncompliance. Walden [27] reported that the US Sunshine Act presently applied only to doctors but from 2022, it will require disclosure from physician assistants, nurse practitioners, and pharmacists too. Ornstein [28] reported that The Sunshine Act has not, however, stopped the problem of non-disclosure by physicians. Kmietowicz [29] reported that in less than half the money paid to health-care professionals was disclosed and the registers lacked details on why money was paid and how was it used. It is essential to have statutory declaration of interests made by all professionals and individuals who worked in health care and keep records that are publicly accessible, and searchable. Feldman [30] suggested that research showed variable and poor recording and without a clear and transparent mechanism for central reporting, searching, and auditing, it will be difficult to improve matters. It is impossible for a citizen to be reassured that a doctor does not have a conflict of interest, or to know when one occurs. Many organizations, experts, health professionals and increasingly the public questions whether quality health care could be delivered under the existing health care system, because health care today harms too frequently and consistently fails to deliver its potential benefits [31,32].  Other emerging problems are Human HIV testing, reporting, use of alternative systems of medicine related which go on in unethical ways. Use of alternative medicine needs to be part of health care, and health professionals learning but practice goes on uncontrolled in unethical ways.  Taylor [33] reported that the application of the ethical principles of justice to these questions concerning health care providers, a benchmark for the determination of types of health care are more or less just than others. 

Dahlawi et all: 

Discussion:   

Neglect of ethics and medical negligence are increasing public health concern globally, as they affect patient safety too Dahlawi [34] reported that WHO has recognized deficiencies in patient safety as global health care issue which needed to be addressed and reviewed and reported.  Due to increasing attension on the topic, there was a sharp increase in the research output on medical negligence. This was of significance as the WHO set in motion a patient safety program almost two decades ago.  Ethics surely needs to be revisited in health professional’s education and health care. It is essential to ensure ethical entry of health professionals to their learning arena and get evaluation done in ethical way. This should be the first step for ethics in medical profession. It is also essential to understand how students learn medical ethics in health care. so that the most effective ways can be planned to help them learn ethics. Medical academia needs to recognize the social and the economic nature of the medical education. Learners should not only identify their learning needs, gaps in knowledge, understanding and skills but also be able to observe the performance of role models, for the right behavior, practice application of skills in classrooms and clinical environments. Equally important, is to reflect on and express views on the learning process and intended outcomes in undergraduate and postgraduate education. The ideal doctor is one who respects his/her art, is never far from his/her patient but not for those who practice for profit, concentrate only where there is greater profit. Basic of health care is preservation of life, relief of sufferings, cure of disease, care of the person, prevention of disease and promotion of health. Doctors must be sensitized to human rights, and gender issues. Withdrawal of life-sustaining treatment from patient needs, discussion for ethical practice.  The words of Hippocrates, ‘The purpose of medicine is to do away with the sufferings of the sick, to lessen the violence of the disease and to refuse to treat those who are overmastered by their disease’.  Patients are seldom seen in line with theory of duty, which defines, the criteria to judge the right and wrong actions by health providers. Ethics seeks to restrain the sources of degradation of the system, ethical management and supervision, also help in improving services and promote consumer protection. Brodhead et al [35] have suggested that the systems may promote the field of behavior analysis as a desirable, consumer-friendly approach to solving socially significant behavior problems. Wu and Green,[36] reported Crossing the Quality Chasm A New Health System for the 21st Century (IOM) committee that authored ‘To Err Is Human’, emphasized that safety problems which occurred because of the system’s inability to translate knowledge into practice, to apply new technology safely and appropriately, and to make best use of its resources, both financial and human. The Quality Chasm report stressed that the rapidly increasing chronic care population only compounded the need for a redesigned health system.

Conclusion:

Serious criticism of medical profession today is because of lack of accountability of organizations, dependence of technology, failure to address important issues in health. Two roles for the doctor, physician and healer physician are linked together. The doctor must function effectively, and healer offer advice and support in matters of health and ministers to the sick. Modern world is shaped to a large extent by technology, but technology must have a human face. One test lead to another, the test results right or wrong, introduce a doubt that must be resolved by more and more tests and health cost increases. The precise functions of medicine may have subtly shifted over the ages, but needs as human beings from the doctors remain the same we go to them because we wish to invoke some change in our lives, either to cure or prevent an illness or influence some unwelcome mental or bodily process. The goal of medicine has always been, the relief of human suffering. The word patient, from Latin patientem, means sufferer and the word physician is from the Greek phusis, or nature. To be engaged in clinical work is to engage oneself with the nature of illness, the nature of recovery and the nature of humanity.  Ethical challenges arise in the context of public health policy, practice and research tools. Mission of the medical doctor is to safeguard the health of the people.                                                                                                                        

The growing public concern about the ethical conduct of healthcare providers highlights the need to incorporate ethics in health   professional’s education and health care in real sense. Knowledge and competencies are the primary goals of formal medical training, but an understanding of professional values and ethical conduct are essential for fostering the development of a good doctor. Ethics needs to be revisited and made integral part of health professionals learning and health care.