How are ethical issues in the laboratory medicine held in Turkey? A perspective view through medical ethics and clinical laboratory science

In an era of “hi-tech” medicine; efficiency, technical sophistication and innovation cause many complicated ethical problems in Laboratory Ethics. Today up to 70% of medical diagnoses rely on different laboratory analyses and this situation emphasises the crucial role that laboratory ethics plays in patient care [1]. Although sustaining high ethical standards remains crucial in both clinical and laboratory practise, and ethical dilemmas are faced daily by laboratory physicians’; ethics does not receive the attention it deserves. Although personal knowledge of the patient is often lacking, the laboratory physician does have intimate knowledge of at least a part of the patientthe specimen-and an unusual three-way contract is made between clinician, laboratory physician and patient. This paper provides an overview on the main ethical issues of laboratory ethics through the perspectives of medical ethics and laboratory science. It is also aimed to show the necessity of education for the laboratory ethics.


Introduction
In an era of "hi-tech" medicine; efficiency, technical sophistication and innovation cause many complicated ethical problems in Laboratory Ethics. Today up to 70% of medical diagnoses rely on different laboratory analyses and this situation emphasises the crucial role that laboratory ethics plays in patient care [1]. Although sustaining high ethical standards remains crucial in both clinical and laboratory practise, and ethical dilemmas are faced daily by laboratory physicians'; ethics does not receive the attention it deserves. Although personal knowledge of the patient is often lacking, the laboratory physician does have intimate knowledge of at least a part of the patientthe specimen-and an unusual three-way contract is made between clinician, laboratory physician and patient.
This paper provides an overview on the main ethical issues of laboratory ethics through the perspectives of medical ethics and laboratory science. It is also aimed to show the necessity of education for the laboratory ethics.

Accuracy of the tests
In laboratory ethics, the first thing to be determined is whether we are dealing with an accurate test. The point to be made is clear: Errors in testing are frequent, and many of the errors occur because of negligence or even culpable ignorance. Accuracy is the percentage of correct results obtained by the test under evaluation compared with the results of a reference or 'gold standard' test [2]. Evaluations of diagnostic tests must be planned with respect to their use for a clearly defined purpose. This will help to avoid the financial and human costs associated with incorrect diagnoses, which can include poor patient care, unnecessary complications, suffering and, in some circumstances, even death [1].

The costs of the tests
Main ethical problems appear in two fields; charge of overtesting and ethics of allocation. The patient does not often ask about cost, and the health care provider does not mention it. Lately, the rising costs of health care have made it important to think about the costs of tests [2]. It should be that not merely financial cost, but physical, psychic, and social costs must be justified.
We must ask whether the money expended on health produces results proportionate to the expenditure. This question of proportionality between cost and benefit becomes particularly acute when we are dealing not with tests done for diagnostic purposes, but with those done routinely as part of the examination of a healthy person. Physicians have been accused of overtesting, that is, using more tests than are necessary for the good of the patient. Critics in the popular press claim that overtesting is due to the health care providers' efforts to protect themselves against malpractice suits which is defined as defensive medicine nowadays.

Testing and informed consent
Tests can sometimes involve more than minimal risks, and even routine tests cost money and require time of the patient. At least some of the elements of informed consent may enter into testing. The patient should be told the purpose of the test and the benefits, to be gained by it, as well as the side effects and the risks beyond the minimum risks of everyday life. The patient should also be told the costs and the amount of time the test may require [2].

Confidentiality
Today there are many sensitive diagnostics and medical situations that require high confidentiality. As the AIDS problem has demonstrated, after detection of a carrier of AIDS there are also many problems related with stigmatisation and discrimination [3]. Since businesses will often, sometimes illegally, turn down applicants with known health problems, breaches of confidentiality in this area can have especially far-reaching consequences. Healthcare professionals should not take part in involuntary screening except when it is legally and ethically justified.

Ethics education
The education about ethics in most clinical science programmes is about ethical issues in research. In Turkey some programmes contain ethics lectures under the medical laboratory techniques courses. These courses are related with laboratory technicians; but not for the education of laboratory physicians. In accreditaton of clinical laboratories ISO 15189 standards are used and these standards also assess the training of laboratory personnel about ethics. For the physicians the ethics is mostly presented as medical ethics which contains general information; so there is a need for special education.
There is an international study containing the largest survey of the teaching of ethics in educational programmes in laboratory medicine or pathology. According to this study, it is stated there is a need for online resources to aid in ethics training in laboratory medicine [4]. Although there is a computer based learning programme in medical ethics and communication skills like MedEthEx Online, there should be more programmes to support this education. There is information in the literature showing that online ethics education programmes have a very sufficient effect on the participants [5]. It can be taken as an important data showing online education programmes based on laboratory ethics would have a positive impact, if face-to-face ethics education is not possible.

Conclusion
All the data discussed in the limitation of a short paper can be seen as an evidence that we need more discussion concerning ethical values in laboratory examinations and concerning the use of these results. Because of rapid advances in laboratory examinations and the lack of empirical ethical research, it is important to chart empirical knowledge about present value conflict situations involved in the laboratory examination process in health care. Above all, it is very important to include ethics lectures in the education of all healthcare professionals working in laboratories.
We have not been able to find a textbook with its focus specifically on ethics and laboratory medicine, and coverage of ethical topics in general textbooks of clinical chemistry and laboratory medicine tends not to be extensive. Ethical issues are one of the most remarkable principles of professional life. We assume that teaching these principles will result in graduation of more successful laboratory personnel, and ultimately, a better laboratory service for the public. More discussions and learning opportunities on laboratory ethical issues are needed in our society to ensure excellent laboratory professionalism.