Ethics in Medicine | Jindal Chest clinic

This presentation explores the ethical principles and dilemmas faced in the medical field.

2. Ethics in Medicine
•Ethics–Greekterm“ethikos”(i.e.customary).
•Moralobligationswhichgovernactionsinbiologicalsciences–medicine,
environmentalandphilosophicalsciences.
Equity(i.e.Fairnessprinciplesofjusticeusedtocorrectorsupplementthelaw)
constitutesthebasisofallethicsinthemodernsociety.
Partlysocialandprofessionalguidelines
Partlylegal(Caselaw/Statutelaw)

3. Medico-Legal Issues
MedicalJurisprudence-ScienceorPhilosophyofLaw(relatedtoMedicine)
MedicalNegligence
•Lackofpropercareandattention
•Culpablecarelessness(Culpable-deservingblame)
MedicalEthics
•Professionalpractice(clinicalindications/Commerce)
•ResearchandTechnology
•Publications

4. Medical Negligence
•Disease-diagnosis/Tests
•MedicalExpertiseDisease–information
•Standardsofcare
•Treatment–Drugs/Interventions
•EmergencyManagement
•Costs/Referrals
•Complications
•ViolationofActs

5. How to Avoid Problems?
1.Follow standard procedures –in place.
2.Consult others / seniors
3.Communicate well with patients / attendants
4.Good record-keeping
5.Adequacy of care (as per standards / Guidelines in place)

6. Why should doctors learn about ethics?
•Unusualinfluenceoverpatients’lives
•Balancetherightsandinterestsofsocietywiththatofpatients
•Civilrightsmovement
•Avoidethicalconflictsandthinkthroughethicaldilemmas
•Avoidjudicialoversightwithlegalandregulatorysystems–Personaland
Institutional

8. BASIC ETHICAL PRINCIPLES
•Autonomy–anindividual’srighttoself-determination
•Beneficence–todogood
•Nonmaleficence-donoharm
•DistributiveJustice-thejustandequitableprovisionoffinitehealth
careresources

9. Evolution of Medical Ethics
Hippocratic tradition
Philosophical inquiries
(Principle based moral theories)
Antiprinciplism
(Competing moral theories)
Crisis
(Conceptual conflicts –Skepticism of morality)
(Pellegrino, 1993)

10. Beneficence
•HasrootsintheHippocraticdoctrineoffosteringthepatient’swell-being
•Moralobligationtopromotegoodnessorbenefittothepatientandfamily,
toprovidecarethatmaintainsorimproveshealth,reducesdisability,and
alleviatesphysical,andexistentialpainandsuffering.
•Littlequarrelregardingnobilityofthesegoals
•Fewconflictsnevertheless

11. Nonmaleficence
•EmbodiedintheHippocraticdictumprimumnonnocere(first,dono
harm)
•Typicallyisseenasamorestrictrequirementthanbeneficence
•Disagreementabouttheproperbalancebetweenbeneficenceand
nonmaleficence

13. Ethics Determinants
•Cultural-social,religiousandethnicvaluesandcustoms
•Economicandcommercialissues
•Legalsystem
•Internationalcodes
•Politicalpower
•Individualbiases,beliefsandrights

14. Autonomy
•Patientsautonomyandtherighttoself-determinationarewellestablished
ethicalprinciplesandlegalrightsinmedicine.
•Manypatientsareincapableofmakingtheirowndecisions,oftencausing
ambiguityanduncertainty,whichcanleadtoconflictsamonghealthcare
providersandfamilies.

15. Distributive Justice
•Thisis,perhapsthemostdifficulttointerpretandimplement
•Personaljustice:physiciansmusttreateachandeverypatientwithrespect
andfairness
•Socialjustice:whichdovetailswithmedicalfutility;inaworldwithlimited
resources,ineffectivetreatmentsforaparticularindividualmaywaste
resourcesbetterspentonappropriatetherapiesforothers

16. Autonomy –Issues & Concepts
•Capacity
•Informed consent
•Surrogate decision making
•The best argument
•Paternalism
•Resuscitation status

17. Capacity
Presumptionthatadultshavetheabilitytomakedecisionsforthemselves
andabletoparticipateintheprocessofinformedconsent
“Incompetent”individuals
•Children
•Prisoners
•Mentallychallenged
•Dependents

18. Informed consent
*Disclosure*Understanding*Voluntariness
Exceptions
•Lifethreateningemergenciesinwhichdelaywillresultinharmtothe
patient
•Patientwaivestherighttoinformedconsent
Informedrefusal
•ImportantinICUswhenconsideringwithdrawingorwithholdinglife
support.

19. Surrogate Decision Making
•Patientlosescapacity
•Mostcommonlyafamilymember:“surrogate”or“proxy”forthe
patient
•Itisthesurrogate’sresponsibilitytorepresentthepersonalvaluesof
thepatient
•Difficultieswhenvaluesetisnotwelldefinedordisagreementamong
familymembers

20. Best Interest Argument
•Whenapatient’swishesareunknownbythefamilymembersandthereisno
designatedproxyforhealthcaredecisions,the“bestinterest”standard
prevails
•Doctorsaremorallyobligatedtooverruleasurrogateifthereisclear
evidencethatdecisionsarebasedonsurrogate’spersonalvaluesthanthe
patient.

21. Advanced directives…
•NowincreasinglyusedforEnd-of-Life&Criticalcare
•Enableapatienttomaintainadegreeofcontroloverhisorherlife,even
afterthecapacitytomakedecisionsislost.
•ThecardcarriedbymanyJehovah’sWitnesses,detailingtheirrefusalto
acceptbloodorbloodproducts.
•Legalstatus:ChangingandisnowbecomingpartofUKlawforthefirst
time.NotyetacceptedinIndianLaw.

22. Medical Ethics: Domains
1.Clinicalpractice
2.MedicalResearch-Human
-Animal
-Laboratory
3.Epidemiological
4.Economicalissues
5.Medicalteaching
6.Biotechnology
7.Management

23. CLINICAL PRACICE
Physiciansarelikekings;theybrooknocontradiction
JohnWebster,1580-1625

24. CLINICAL PRACTICE ISSUES
1.End-ofLifeCare&Dignityofdeath:
PalliativeCareand“Allowingtodie”
(Euthanasia–“assisted”and“mercykilling”)
2.Organtransplantation
Live-donor
Cadaver–Brainstemdeath
3.Sexselection–Abortion
4.AssistedReproduction:
Ovumdonation
Surrogatemotherhood…
5.GeneticEngineering
6.Cloning

25. END-OF-LIFE (TERMINAL) CARE

26. Death
Time
Health Status
TRAJECTORIES of Death
1. Sudden Death 2. Progressive Illness
Death
Time
Health Status

27. Death
Time
Decline
Health Status
3. Slow decline and Crises

28. Problems of the Terminally Sick Patients
1.Fearofdeath
2.Symptomsandsuffering
3.Socialisolation
4.Financialpressures
5.Medicaldisinterest
6.Nihilisticapproaches
7.Denialofdeath

29. Important Issues for Doctors
•Palliativecare–reliefofsymptomsvs.Lifeprolongingtreatments
•Hospiceversushospitalization
•Tellingtheobvious
•Managementinthelasthoursofliving
•Patient’sobligations:Family,financial,social,spiritual,religious
•Afterdeathhandling
•Bereavement

30. Acts and Omissions
•Treatmentwithheld/withdrawnevenifallowsdiseaseprogressiontonatural
death
•Importantdistinctionbetweenallowingthepatienttodieanaturaldeath
(allowingillnessprogressionnormally)andactivelydoingit(intentional
killing)
•Decisionbasedoninabilityofpatienttobenefitfromthetreatment
(Read“GuidelinesforWithdrawalofTreatmentofIrreversiblyCriticallyIll
patientsonAssistedRespiratorySupports”www.pgimer.nic.in)

31. Euthanasia and physician –assisted
suicide
•Activeeuthanasiaisillegal-TheNetherlandsandBelgiumpermit
voluntaryactiveeuthanasiabylethalinjections
•Physician-assistedsuicideislegalinsomecountriesandstatesofNorth
America,suchasSwitzerlandandOregon
•IndianCourtsdonotaccepttheconcepts

32. Do not resuscitate (DNR) orders
•CPRishighlyeffectiveinventricularfibrillation
•Notsuccessfulasaroutinetoalldyingpatients(criticallyillpatientswith
multiorganfailureoroverwhelmingsepsis)
•DNRordershasleadtoconflictb/wdoctorsandpatient’sfamilies
•NosanctionforDNRinIndia
•Goodcommunication,whyCPRwillbecommencedresolvesmanysuch
issues.CPRmaynotbewiseornecessaryinknown,end-stagediseasein
theabsenceofareversiblefactor

33. Rule of double effect (RDE)
•Interminalcare,thereisanobligationtomaximizethepatient’scomfort
andminimizethepain&distress
•Drugssuchasopioidsandbenzodiazepineareoftenrequiredmore
liberally
•Theharmfuleffectsofdrugsmayappeartohastenapatient’sdeath(i.e.
doubleeffect)
•TheUSSupremeCourthasgivenRDElegitimacy

34. Medical Commerce
“Wecannotexpecttoseemuchactionuntilenoughpolicymakerslosetheir
fascinationwiththeviewthathospitalsarebasicallybusinesses”.
ArnolRelman,NEJM1985
Ahospitalisbothalikeandfundamentallydifferentfromafactory,public
schoolorcorporateheadquarters.
ChaslesRosenberg,1987

35. A CODE OF MEDICAL ETHICS
ForinformationoftheRegisteredMedicalPractitionersonthePunjabMedical
Register
PartI:AcodeofMedicalEthics
GeneralAdvice
PartII:Warningnotice
Somemattersofforensicimportance

36. Health-Research: Ethical Issues
1.Subversionofresearch
Entrepreneurship
Conflictsofinterest
Growingalliance
2.Dangers:Unknownrisksvspromiseofbenefits
3.Patentprotection
4.Citation&Publication

37. BIOETHICS in Health-Research
•Restrictive/prohibitivetogrowth?
WHYNEEDED?
•Preventingmisguidance
•Warningfuturemisuse
•Protectingthepublicinterest
Bioethicspromoteadisciplinedapproach

38. Specific Areas of Concern
1.ObjectivesofResearch:Methodology&Safety;Costsofinvestigations;
Sponsorships
2.AnimalResearch:Numbers,Up-keep,Animalrights
3.Newdrugdevelopment-DNAandgenetictechnology
4.Geneticallymodifiedfoodsandplantbaseddrugs
5.Useoflivingcells;cell-lines
6.Assistedreproductiontechniques
7.Chimeratechnology
8.Biobanks,humangenepatents,stemcellresearch,humancloning
9.Bioinformaticsandbiologicalweapons
10.Plagiarism&Falseclaims

39. ICMR Guidelines -I
•Essentiality
•Voluntariness–informedconsentandcommunityagreement
•Non-exploitation
•Privacyandconfidentiality
•Precautionsandriskminimization

40. ICMR Guidelines -II
•Professionalcompetence
•Accountabilityandtransparency
•Maximizationofthepublicinterestandofdistributivejustice
•Institutionalarrangements
•Publicdomain
•Totalityofresponsibility
•Compliance

41. Publication & Authorship
For“intellectualworks”:Papers,Projectreports,images,electronic(etc.)
I.CitationandCopy-rightissues
II.Plagiarism(Passoffanotherperson’sthoughts,writingsasone’sown).
III.Authorshipissues:Itinvolves-
i.Accountability:Intellectual,Professional,Moral,Social,Legal
ii.ResponsibilityforContentsErrors&Omissions

42. Fundamental principals for authorship
Allthree
1.Substantial,intellectualcontribution
2.Participationinwriting,reviewingofthedraftsandapprovalofthefinal
version
3.Precisecontributionshouldbeidentifiableandjustifiable.
Authorshipisnotacharity–shouldbeearnedasabove.

43. What is intellectual contribution?
1.Conceptualization
2.Performanceofexperimentsanddatacollection
3.Conductinganalysisandinterpretingdata
4.Reviewingliterature,assessingaccuracy&relevancy,writingsignificant
partofpaper
5.Involvementindatacollection,verification,supervisionandguidance,
analysisandwriting(throughoutorformostofthestudyperiod).

44. Framing Ethics: Difficult Issues
•ImperviousvsResponsive
•Fusionoftheoryandpractice
•Conceptualframeworkof
Rightorwrong
Goodorbad
Conflictsofmorality
Otherconflicts:Personal/Social/Cultural/Legal/Professional/
Commercial/Political

45. Ethical Management Guidelines for
Leaders of Academic Medical Centres
•Threats(fiscal/others)toAHCs
•Powerconcentrationinleaders–
“Ethicalconceptsofprofessionalismandjusticerequired”
“Voluntarycooperationofallstakeholders”
“Fosteringfinancialviability”
Chervenaketal,AcadMed2002

46. Value system vs. Decision making
Itisnotonlythatvaluesystemsinevitablycreepintobiasdecision-making,
althoughtheydo.Itisratherthatpolicymakinglogicallyrequiresasystem
ofvalues.Inlargepartthosevaluesaredeterminedbyculture.
RobertVeatch

47. Handling Ethical Concerns
New discovery / vision
Social / Political /
Professionalcriticism / concerns
Commissions
Guidelines
Laws / Legislation

48. Part I
A Code of Medical Ethics (Pb. Med. Council)
1.DignityofProfessionofmedicinemaintainedonalloccasions…followingandsimilar
practicesavoided.
a.Solicitingpvt.Practice…advts.
b.Derivingpecuniaryprofitfromsaleofanysecretremedy
c.Shareinprofits
d.Publishingorsanctioningpublicationofreportsofcases,operations,lettersofthanks…
e.Coveringpersonsnotregd.UnderMedicalActs
f.Keepinganopenshop…
g.Talkingtoorassociationwiththeprofessionunconnected…
h.Agreeingtotreatpatientontheterms“nocurenopayment”basis
i.Givingcertificatesundertheirownnamestomanufacturersofsecretremedies.

49. Not Necessarily a Right to Authorship 1
•Mereprovisionoffunds,facilitiesoradministrativesupports.
•Mereparticipationindatacollection.
•Workdonebyanemployeeincourseofhis/heremploymentfora
specificpurpose.
•BeingHeadofaDepartment,doesnotqualitytobeauthor.Scientific
contributionisrequiredforauthorship.
•Authorshipdistributionshouldnotbeacharity–itshouldbeearned.
•Preservationofrawdataistheresponsibilityoftheprimaryauthorinthe
department.

50. Terminal sedation
•TheUSSupremeCourthassanctionedthepracticeofterminalsedation,in
whichthepatientsarerenderedcomatoseandthenmayhavenutritionand
hydrationwithdrawn
•Thoughtheissueiscontentious,theCourtsallowthispracticeifbasedon
informedconsent
•NosuchsanctioninIndia.

51. Not Necessarily a Right to Authorship 2
Laboratorydata
Routinediagnosticortreatmentinvestigationsinalaboratoryforpatients,
unless:
i,thetestsarecarriedoutforpurposeofthestudy;
ii,asignificantlaboratorydataisbeinganalysedandreported;
iii,thelaboratorydataconstitutesorformsthesubjectofthestudy;
iv,Multiplelaboratorydatafromasinglelaboratoryaretakenandhighlighted;
v,Evensingledata,highlightedincasereport.

52. Not Necessarily a Right to Authorship 3
Clinicaldata:Routineregistrationofapatient/sinanOPD/Clinic/Warddoes
notconstitutetherighttoauthorship,unless:
i,theworkisbasedononeormoreofthesepatientsorfromthematerialfrom
thesepatients,includingthestoredsamples.
ii,astudyisbeingdonewithreferencetoaclinicalissue(eg.onclinical
patterns,therapy,prognosisandnaturalhistory).

53. Order of Authorship
•Theleadauthorisgenerallythepersonwhotooktheleadandcontributed
maximally.
•Thesubsequentorderdoesusuallynotspeakoftherespectivecontribution
ofindividualauthors.Thiscouldbeeitheralphabeticalinorderoras
agreeduponbyalltheco-authors.
•Authorsshouldspecifyintheirmanuscriptadescriptionofthe
contributionsofeachauthor.Thisshouldatleastbeidentifiableand
justifiable.

54. Multi-centre Group and collaborative studies
•Thegroupshouldidentifytheindividual/swhoacceptdirectresponsibilityforthe
manuscript.Theseindividualsshouldfullymeetthethreeprinciplecriteriadefined
earlier.
•Theissueofauthorshipshouldbefranklydiscussedveryearlyinthecourseofthe
workandamutualdecisionshouldbemadeinwriting.
•Thefirstortheseniorauthorshouldgenerallycommunicatewiththejournal-editor
andothersrelatedtothepublication.He/shewilltakealltheresponsibilityasthe
primaryauthor.
Incasethefirstauthorisastudentinthedepartment,thecorrespondingauthorcouldbe
theleaderofthegroupperformingthestudy.
•Thefirstorthecorrespondingauthorshouldbeabletospeakonanddefendthe
paper.

55. A CODE OF MEDICAL ETHICS
•Shouldnotmeetinconsultationwithnon-registeredpractitioners
•Observepunctualityinconsultation
•Announcingresultofconsultation
•Differencesofopinionshouldnotbedivulgedunnecessarily,but..
•Attendanceshouldceasewhenconsultationisconcluded
•Shouldscrupulouslyavoidinterferencewithorremarksuponthe
treatmentordiagnosis
•Communicatetotherequestingpractitioner.

56. Justifiedinrefusingtocontinueattendanceoncases
a.Anotherpractitionerinattendance
b.Otherremedies(thanhis)beingused
c.Hisremediesrefused
d.Whereillnessisanimposture
e.Patientpersistsinabuseofopium,alcohol,chloraletc.
f.Subsequentchangeofmind…
Heisnotinanywayboundtogiveupacasebecausehecannot
cureitsolongasthepatientdesirehisservices.

57. Disputes & Plagiarism
Disputesoverauthorship&otherissuesshouldbebestsettledatthelocallevel
bytheauthorsthemselvesorwiththehelpofthedepartmenthead.
Iflocaleffortsfail,theDirector/Dean/IRBoftheInstituteshouldbeinformed.
Itdoesnogoodbydirectlywritingtothejournal’soffice/editor.
ComplaintsentdirectlytoanEditorofajournallowersthereputationofthe
institution.ThepersonshouldconsulttheDean/Directorbeforewriting
totheEditor.

58. Preservepatient’ssecrets.Notboundtoanswertopolicemen,solicitors,
vakils…;onlyattheexpressdiscretionofjudgeorMagistratespresiding
inaCourtofLaw.
NotvolunteertogiveevidenceinaCourtofLawagainsthispatient.Should
notappearsubpoena.

59. Ethical Practices and National
Ethics-Guidelines / Legislation
USA:NationalBioethicsCommission
India:IndianCouncilofMedResearch
Pakistan:LahoreStudy(Humayunetal2008)Inadequateinhospitals
Iran:Structuredapproachtoidentify,analyseandresolveethicalissues–
Nationalguidelines(Zahedi2008)

60. Brazilian Experience
Threedifferentcommitteesinhospitals:
1.MedicalEthicsCommittee:Toevaluateprofessionalconflicts
2.ResearchEthicsCommittee
3.ClinicalBioethicsCommittee/Rounds
i.Provideconsultancyonethicalquestions
ii.Suggestinstitutionalguidelines
iii.Transdisciplinaryperspective
Goldimetal2008

61. Professional Domains
Knowing(Education&Research)
Doing(Practice)
Helping(Management)
Thesearethethree‘socialvalues’inarecognizedconceptofanyprofession.
Meston,1981

62. National Bioethics Commission (US)
1.Handlingdifferences–Worldview
•Politicalorientationanddiscipline
•Dignityofdifference
•Understandingthanagreement
2.Experimentingwith‘prophetic’bioethics
•Critiqueofmodernmedicine
•Alternativeto“regulatorybioethics”(compromise-seeking)

63. Ethics of questionnaire-based research
“Itdoesn'tcostanythingjusttoask,doesit?”
•Balanceofbenefitsvsharms/time
•Harm–Creating/reinforcinganxietyaboutlifethreateningillnesses;level
ofcare;legalissues.Harmstoparticipatingprofessionals.
Evansetal,JMedEthics2002

64. Public Policy Formulation
Public Policy leaders
N.G.Os.
Decision makers
Public “scientific literacy” is poor –short of acceptable criteria (only 7% in
American adults –1979)
•Attitudes towards biotechnology ?
•Knowledge –attitude nexus
(Miller 1985; Bastels 1996;
Althaus 1998; Sturgis 2005)

65. Patent Protection
•Intellectualpropertyrights-Trademark/copyrights
•RightofresearchervsSocietalissues
•Useofthepast“unpatented”knowledgeandwisdom
•Hidinginformation
•Depriving“knowntreatments”-Unethicalculprit

66. Patent as Unethical Culprit
•CreationofWesternresearch
•Keepingpriceshigh
•Deprivingtheglobalpoor
•Creatingasocialdivideandimbalance
•Unitingfutureresearchanddevelopment

67. Special Ethical Considerations
MedicalFutility
•Thereisgeneralagreementthatphysiciansnevershouldunilaterallymake
decisionsaboutfutilitywithoutexplainingtothepatientandfamily.
•Thetrendinfutilitycasesisthatwhilecourtdidnotpermitlifesupportlimit
prospectivelyonappealfromdoctors,theytendtodefenddecisionstolimit
lifesustainingtherapywhenmadewithinacceptableprofessionalstandards

68. Drawbacks in the current strategies
•Thedominanceofautonomyoverthatofbeneficenceoftenleadsto
inappropriatetreatment
•Thedoctoroftenfindhimselfinmoraldilemmawithoutadequatelegalsafe
guardagainstmisinformeddecisionbyfamilies
•Inthispartoftheworldproblemsarecompoundedbytheneedtoration
recoursesandmoralobligationtoprotectfamiliesfromfinancialruin
•Societalpressurealsoerodetheselfesteem

69. The Indian Scenario
•InIndialegalopinionandlegalizationrelatingtocriticalcareisscarce
•Thereisnoclearlystatedlegalopinionregardingdiscontinuationoflife
supportsystemeveninbraindeadpatients
•InIndiaArticle21providestherighttolife.Howevertheconceptof
autonomyisstillweak

70. The Indian Scenario…
•TherehavebeenapaucityofcasesdealtwithbyIndiancourtsinthematter
ofendoflifecare
•IntheP-RathinamVSUnionofIndia1994.Thesupremecourtconceded
thatinthecaseofterminalillnessattemptstohastendeathmaybeviewed
asanaccelerationofdyingprocessalreadystarted
•Thecourtacknowledgedthat“apersoncannotbeforcedtoenjoytheright
tolifetohisdetriment,disadvantageordislike”

71. The Indian Scenario…
•InthecaseofGianKaurvsStateofPunjabthejudgmentdisallowsthe
conceptofeuthanasia
•InIndiathepredominantfactorimpactsdecisionmakingistheunbearable
financialburdenthatitentails

72. Science or Philosophy of Medical
Jurisprudence Law (related to Medicine)
MedicalNegligence
Lackofpropercareandattention
Culpablecarelessness
(Culpable-deservingblame)
MedicalEthics
• Professionalpractice(clinicalindications/Commerce)
• ResearchandTechnology
• Publications

73. Principles : Fundamental
•Autonomy(selfrule)
•Justice(Loveofothers)
•Non-maleficence(Lovinglife,donoharm)
•Beneficence(Lovinggood)
Macer1998

74. •Ethics–Greekterm“ethikos”,
Meaningcustomary,ornature,isthestudyofstandardsofconductand
moraljudgment.
•Systemorcodeofmoralsofaparticularperson,religion,group,or
profession.(Webster,1980)
“Medicalethicsisspecificallyconcernedwithmoralprinciplesand
decisionsinthecontextofmedicalpractice,policyandresearch”

75. EQUITY
•Fairness
•Principlesofjusticeusedtocorrectorsupplementthelaw.
Equityconstitutesthebasisofallethicsinthemodernsociety.

76. Positive rights vs. Negative rights
•“negativeright”torefuse:basedonautonomy
andinformedconsent,constitutionalrightsof
privacy,libertyandcommonlawagainst
battery.
•“positiveright”todemandtreatmentlimited
bythephysician’sclinicaljudgmentandhas
nofoundationsinbiomedicalethicsorinlaw.

77. Whatdoesethicalviolationbydoctorsdo?
–Damagethereputationoftheprofessionandtheperson
–Erodestrustondoctors
–Interferewithpeopleseekingtherapy
–Invitejudicialoversightwithlegalandregulatorysystems–Personal
andInstitutional

78. HIPPOCRATIC ETHICS
•OathAscetic(self-discipline)philosophy
•Obligationsof
Beneficence(helpful)
Nonmaleficence(official)
Confidentiality
•Prohibitionagainsteuthanasia,abortion,surgery,sexualrelationswithpt.
•“Pure”life–ofvirtue
Lateradditions:rulesregardingdress,gossip,Reputation,cleanliness,truth-telling,
education,Consultationsetc.Emphasisonduty,comparison,loveandfriendship