AWARENESS OF MEDICAL SPECIALISTS AND PATIENTS IN BULGARIA OF ETHICS COMMITTEES AND THE BENEFITS OF THEIR WORK

In today’s healthcare, the role of morality emerges to the forefront as a result of the high degree of uncertainty in our modern environment. Ethically responsible behaviour is therefore perceived as a prerequisite for preventing and counteracting a number of moral risks in society. With regard to moral hazard and responsibility, ethical codes represent a rational control mechanism, lowering the extent of the probability of moral peril. Ethics committees are also founded based on such ethical codes, the purpose of such committees being the proclamation and observation of the principles and norms set forth. At the healthcare institutions of the Republic of Bulgaria, ethics committees are established that are based on the principles of medical ethics and medical law. The significance with which ethics committees are charged regarding the sustainable development of the healthcare system consists of protecting the patients, the medical professionals and the institution itself. Awareness of the significance, functions and benefits of ethics committees and their impact on the medical practice and patients in Bulgaria is, however, insufficiently low. In a questionnaire survey conducted among 149 medical specialists employed at three medical establishments for hospital care in the country, and 269 patients under treatment at them, at being asked “Do you think that ethics committees contribute to protecting and respecting patients’ rights?”, 26.2% of the respondents among the medical professionals replied that they are not sure, while 25.7% of did not provide an answer to the question thus asked due to being unfamiliar with ethics committees as an institutionalized body and their functions. The analysis of the results of the abovementioned survey among medical professionals and patients evidences a low level of awareness of the ethics committees and their work on the territory of the Republic of Bulgaria. It is essential for healthcare establishments to enhance their education and information channels with regard to the existence of ethics committees and the benefits of their work. Such a change would lead to improving the quality of healthcare services provided and the overall health of the nation.


INTRODUCTION:
The healthcare system in Bulgaria spans a number of processes and activities to do with financing, managing and providing healthcare services.The modern healthcare system is based on equality of access to healthcare, solidarity, the right of choice and efficiency of the resources expended.According to the Bulgarian Health Act, the protection of the citizens' health as a condition of full physical, mental and social well-being is a national priority, and it shall be guaranteed by the government [1].The governmental role in healthcare delivery is to regulate all specific processes so as to guarantee that the constitutionally and legally prescribed rights and obligations of every citizen of the Republic of Bulgaria.
In today's healthcare, the role of morality emerges to the forefront, which is the consequence of the uncertainty in our modern environment.Ethically responsible behaviour is perceived as a prerequisite for preventing and counteracting a multitude of moral risks in society [2,3].
With regard to moral hazard and responsibility, ethical codes constitute a rational control mechanism; they lower the extent of the probability of moral peril and in this sense play a preventive role, promoting moral responsibility.The ethical codes produced by different groups and communities represent their key values and principles.Ethics committees are also founded based on such ethical codes, the purpose of these committees being the promulgation and observation of the principles and norms set forth.
The medical establishments in the Republic of Bulgaria are an essential component of the national healthcare system [4].Ethics committees based on the principles of medical ethics and medical law are founded at such healthcare establishments so as to perform the following fundamental functions: drafting statements on incoming complaints by patients or their representatives, as well as initiating inquiry procedures in the case of unethical relationships arising between hospital personnel members and patients, or between the former and the under-and post-https://doi.org/10.5272/jimab.2018241.1899graduate students at the relevant healthcare institution [5].
Ethics committees constitute the linking unit between society's values and the healthcare establishment in which certain patients are treated and in which case ethical dilemmas arise.Ethics committees in healthcare establishments perform several fundamental functions: educational -they support medical staff, educating it about the importance of and working to ethical standards, guidelines and directions, thus contributing to enhancing the understanding of medical staff on legal and bioethical issues; advisory -they support patients, their families, medical practitioners in charge or other health professionals in identifying, defining and solving ethical dilemmas; and lawmaking -they create different guidelines and directions, as well as suggest and recommend administrative measures and guidance on medical ethics problems that have arisen.The basic principles on which the ethics committees are established and operate include those of independence, competence, transparency and dialogue [6].
The ethics committees that are founded at healthcare establishments aim to assist medical practitioners and other medical and non-medical professionals at the hospital, as well as patients and their families, in coping with the ethical and legal dilemmas they face in their everyday lives.

MATERIALS AND METHODS:
The purpose of this article is to study, analyse and compare the opinions of medical professionals and patients in the Republic of Bulgaria regarding the benefits of the ethics committees at healthcare establishments; on whether their existence is justified and if education and awareness on this topic need to be improved.
To achieve this purpose, a questionnaire survey was conducted.The survey covered 149 medical professionals and 269 patients.The selection was random -without any respondents being handpicked -which justifies a claim to representativeness of the results.The confidence interval of P (t) = 0.05 is indicative as far as the evaluation of the accuracy of the indicators analysed is concerned.
The logical unit of observation in the survey were medical specialists and patients.
The technical unit of observation were the Doverie Medical Complex-Sofia, First Multi-Profile Hospital for Active Treatment-Sofia EAD and Multi-Profile Hospital for Active Treatment "Dr Atanas Dafovski" AD, Kardzhali.The choice of healthcare institutions was random: two healthcare institutions in Sofia and one in the town of Kardzhali.

Time and place of observation:
The survey among medical specialists and patients was conducted in the period of 05.01.2017 to 05. 02.2017 at the DOVERIE Hospital -Sofia, First Hospital of Sofia, ATANAS DAFOVSKI "JSC -Kardzhali.

Survey Documentation
The main documents used to collect primary information were: A questionnaire for medical professionals; A questionnaire for patients.A comprehensive methodology was employed to objectify the observed patterns and analyse the data collected.Indicators were evaluated at a significance level of P> 0.05, interpreting dependencies whose existence cannot be questioned P (t) = 0.95.
A quantitative analysis were performed using a software package of statistics programs -SPSS 17.0.MICROSOFT OFFICE products were used for data and graphics processing and presentation.
In order to achieve the goal at hand in this article, the questionnaire survey method, comparative and critical analysis were applied.

RESULTS AND DISCUSSION:
1. Demographic characteristics of respondents.Of the 149 interviewed medical professionals, 15.4% were male and 84.6% were female; while of the 269 patients that participated in the survey, 65.1% of the respondents were female and only 34.9% were male.To account for a more detailed profile of the respondents, these were asked, "What is your family status?".Of the surveyed medical specialists, 15.4% indicated that they were not married; 68.5% responded they were married; 3.4% replied that they were separated but not divorced; 8.1 % of respondents answered that they were divorced, 4% -widowed and only 0.7% of the surveyed medical specialists did not indicate their family status.Patients were asked an identical question, with 20.1% of the respondents replying that they were not married, 55.8% -that they were married; 3.3% answered that they were separated, but not divorced; 10.8% replied that they were divorced; and 10% of the respondents indicated that they were widowed.Of the 149 medical professionals interviewed, 6% lived in villages, 55% -in a town or city, and 38.9% lived in the capital; while of the 269 patients surveyed, 14.1% of respondents answered that they lived in a village, 50, 2% lived in a town or city and 35.7% of the respondents indicated that they lived in the capital.When asked about their education, among the treated patients in the three medical establishments, 46.1% of the respondents indicated that they had a higher education degree, 36.4% said they had a secondary education degree, and 11.9% said that were specialists, only 0.7% of patients indicating that they had no education degree.These results imply a substantial degree of patient awareness and access to information.

Awareness of medical professionals and patients about the types of ethics committees.
To measure the awareness of medical professionals and patients regarding ethics committees acting on the territory of the country, a specific question was asked, "Do you know what types of ethics committees exist in Bulgaria?".According to 70.5% of the medical professionals and 82.2% of the patients in the healthcare establishments, there are no ethics committees.Only 12.1% of the medical professionals and 8.2% of the patients indicated they were aware that there are scientific research ethics committees at the medical universities in the country.Only 6% of the medical professionals and 1.5% of the patients surveyed reported that they were informed of the existence and func-tioning of an ethics committee for multi-centric studies.Only about a quarter of the healthcare professionals, or 25.5%, and 9.7% of the patients surveyed were informed that ethics committees exist at the Bulgarian Medical Association, the Bulgarian Dental Association and the Bulgarian Association of Healthcare Professionals.
To find out the views of medical professionals and patients regarding the benefits of ethics committees, they were asked: "Do you believe that ethics committees lead to protection and respect of patients' rights?" Figure 1 presents the views of medical professionals and patients regarding the role of ethics committees as a warrantor of protecting and respecting patients' rights.There is a statistically significant difference (Chi-Square Tests, Linear-by-Linear Association -25,542).iar with the concept of ethics committees, their role and the benefits from their functioning.These results reveal a low degree of awareness among healthcare professionals, as well as the need for change and for more information.Only 6.3% of the respondents among patients shared that they are not sure whether ethics committees contribute to protecting and observing their rights, while 25.7% of the respondents, or 69 patients, did not choose any of the suggested answers.This illustrates the low degree of familiarity with this topic among patients in Bulgaria and their consequent inability to choose an answer among the options provided.Such a lack of information acts as a barrier to accessing and benefiting from ethics committees and makes patients insecure, vulnerable and distrustful.
To find out the opinion of medical professionals and patients regarding the necessity for ethics committees to exist, they were asked: "Do you think that ethics committees should exist?" Figure 2 summarizes the views of medical professionals and patients regarding whether ethics committees should exist.No statistically significant difference Chi-Square Tests, Linear-by-Linear Association -1,942.

Fig. 2. Opinion of medical professionals and patients on whether ethics committees should exist.
The chart indicates that a statistically significant difference is to be observed between the answers provided by the medical professionals and the patients.Among medical professionals, 55.7% consider ethics committees to contribute to protecting and respecting patients' rights; while only 30.9% of the respondents among patients have indicated a similar response.Figure 1 clearly evidences that healthcare professionals are better acquainted with ethics committees' functions and perceive the benefit from their existence more tangibly in comparison to patients; while less than one-third of the patients surveyed are aware of the existence of and benefits of the work of ethics committees.Only 18.1% of medical professionals hold the opinion that ethics committees are not conducive to respecting and protecting patients' rights, while 37.2% of patients reply that in their opinions ECs do not contribute to protecting and respecting their own rights.Here, again, a negative tendency among patients is outlined, in contrast to the answers of the medical professionals.It is obvious that healthcare professionals are better informed about the ethics committees at healthcare establishments in Bulgaria.A high percentage of medical specialists -26.2%, report they are not sure whether the ethics committees lead to protecting and observing patients' rights, which indicates that a large percentage of healthcare professionals are not famil- The results indicate that there is no statistically significant difference in the answers provided by medical professionals and patients, yet disparities are at hand.According to 28.9% of the medical professionals and 30.9% of the patients, the ethics committees should exist, and the benefits of their work are tangible.The positive attitude of both healthcare professionals and patients regarding ethics committees and the need for their existence clearly stands out here.Nearly one-third of all respondents provided a positive answer, stating that they appreciate the benefits of the ethics committees' work and are aware that they have a rightful place in healthcare establishments.According to 35.6% of medical professionals and 21.2% of all patients, ethics committees should exist, although they personally do not consider them of any use to medical practitioners.The results indicate that medical professionals are more conscious of the need for ethics committees, and even if they do not understand their nature and benefits in details, their preference is for such committees to exist.Only 6%, or 9 healthcare professionals, have answered that ethics committees are superfluous; whereas 30 patients, i.e. 11.2%, responded that there is no need for ethics committees to operate.This result shows that healthcare professionals are better acquainted with the added value of the ethics committees' work, with only six of these respondents indicating that there is no need for the ethics committees to exist.29.5% of medical professionals and 36.8% of patients indicated that they are not fully convinced of such a need.The largest part of healthcare professionals (44) and most patients (99) reported they are not sure of the answer and did not have a clear position.The healthcare professionals without a clear position were 7.3% less than the patients who submitted this response, which evidences that the employees of the three medical establishments were better informed than the patients being treated in these same health establishments.
From the almost even distribution of the response options selected, it follows that: ethics committees should exist, as the added benefit from their work is substantial; they must operate, even if they are not of any use to the medical professionals.It is evident that both medical professionals and patients are not sure what to answer, which is a definite sign of confusion on their part.They do not hold similar positions, and this is probably due to the substantially different degrees of awareness on the topic among medical professionals and patients.Every medical practitioner and each patient should individually be informed about the existence, functions and powers of the ethics committees, as well as about the outcome of their work.
The lack of systematization of information on ethics committees operating on the territory of the country causes medical professionals and patients alike to be unable to gain sufficient understanding about the existing ethics committees.There are no available opportunities for additional training or the acquisition of specialized knowledge by medical professionals on ethical issues in the medical practice.
So as to examine the opinion of medical professionals and patients regarding the necessity for the medical establishments to be committed to informing their employees and patients about the functions of ethics committees in the case when such committees exist on their premises, they were asked: "Do you think that medical institutions need to inform their employees and patients to the functions of ethics committees?" Table 1 presents the opinions of medical professionals and patients regarding the necessity for the medical establishments to inform their employees and patients about the functions of ethics committees.No statistically significant difference Chi-Square Tests, Linear-by-Linear Association -1,231.
Table 1.Opinion of medical professionals and patients regarding the need for healthcare establishments to educate their employees and patients about the functions of the ethics committees operating at the healthcare facility.
According to 48.3% of the medical professionals and 38.7% of the patients surveyed, the medical establishments must necessarily introduce their employees and patients to the functions of the ethics committee.A significant percentage of health professionals surveyed, or almost half of them, indicated that healthcare establishments should provide more information about ethics committees existing at healthcare establishments.The results point that 33.6% of medical specialists and almost half of the respond-ent patients, or 44.6%, are of the opinion that medical establishments must necessarily familiarize their employees with the ethics committees' functions and introduce patients to ethics committee functions only at their express desire.This indicates that half of the patients surveyed would like for healthcare professionals to be educated about the ethics committee at the specific healthcare establishments so that patients can get informed if they explicitly request so.

Do you think that medical establishments need to introduce their employees and patients to the functions of the Ethics committees?
Total patients hold the opinion that it is not necessary for healthcare institutions to familiarize their employees and patients with the functions of the ethics committee.These results evidence that both healthcare professionals and patients strongly desire for information on ethics committees to be made freely accessible, and for healthcare institutions themselves to be involved in providing this information.

CONCLUSIONS
The analysis of the results of the survey among medical professionals and patients evidences a low level of awareness about the existence of ethics committees and the functions they perform on the territory of the country.A large percentage of the practicing medical professionals and the patients undergoing treatment are unaware of the functions and benefits of ethics committees.This makes it difficult for such committees to operate and does not al- low them to fulfil their functions and goals.The survey results indicate that the affected parties (namely, medical professionals and patients alike) insist on changes being introduced and on healthcare institutions' addressing the issue.The latter need to optimize their education and information channels regarding the existence of ethics committees and the benefits of their operating.A change toward this would improve the quality of services provided and the health of the nation.[7] According to Art. 52 of the Constitution, citizens have the right to "health insurance which guarantees them accessible medical aid and to free medical services under conditions and procedures regulated by law" [8].This provision of the Constitution delegates to the government the obligation to guarantee the health of the nation and to provide for respecting the powers vested in them.

Fig. 1 .
Fig. 1.Opinions of medical specialists and patients regarding the benefits of ethics committees for patients.
Only 18.1% of the medical professionals and 16.7% of the