Medical Ethics

I

Introduction

Medical Ethics or Bioethics, study and application of moral values, rights, and duties in the fields of medical treatment and research. Medical decisions involving moral issues are made every day in diverse situations such as the relationship between patient and physician, the treatment of human and animal subjects in biomedical experimentation, the allocation of scarce medical resources, the complex questions that surround the beginning and the end of a human life, and the conduct of clinical medicine and life-sciences research.

Medical ethics traces its roots back as far as ancient Greece, but the field gained particular prominence in the late 20th century. Many of the current issues in medical ethics are the product of advances in scientific knowledge and biomedical technology. These advances have presented humanity not only with great progress in treating and preventing disease but also with new questions and uncertainties about the basic nature of life and death. As people have grappled with issues on the frontier of medical science and research, medical ethics has grown into a separate profession and field of study. Professional medical ethicists bring expertise from fields such as philosophy, social sciences, medicine, research science, law, and theology.

Medical ethicists serve as advisors to hospitals and other health-care institutions. They have also served as advisors to government at various levels. For example, experts in medical ethics assisted the United States government from 1974 to 1978 as members of the National Commission for the Protection of Human Subjects of Medical Research. The commission was formed in response to several large-scale experiments that used human subjects who were tricked into participating. In the late 1990s the National Bioethics Advisory Commission, at the direction of President Bill Clinton, studied issues related to the cloning of human beings. Ethicists also serve as advisors to state legislatures in the writing of laws concerning the decision to end life support, the use of genetic testing, physician-assisted suicide, and other matters. Medical ethics has even become part of the landscape in the commercial world of science. An increasing number of firms involved in biotechnology (the business of applying biological and genetic research to the development of new drugs and other products) regularly consult with medical ethicists about business and research practices.

The field of medical ethics is also an international discipline. The World Health Organization founded the Council for International Organizations of Medical Sciences in 1949 to collect worldwide data on the use of human subjects in research. In 1993 the United Nations Educational, Scientific, and Cultural Organization (UNESCO) established an International Bioethics Committee to examine and monitor worldwide issues in medicine and life-sciences research. The UNESCO directory lists more than 500 centers outside the United States. The International Association of Bioethics was founded in 1997 to facilitate the exchange of information in medical ethics issues and to encourage research and teaching in the field.

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In the United States and Canada more than 25 universities offer degrees in medical ethics. In many instances, the subject is also part of the curriculum in the education of physicians and other health-care professionals. Many medical schools include ethics courses that examine topics such as theories of moral decision-making and the responsible conduct of medical research.

II

History

The examination of moral issues in medicine largely began with the Greeks in the 4th century bc. The Greek physician Hippocrates is associated with more than 70 works pertaining to medicine. However, modern scholars are not certain how many of these works can be attributed to Hippocrates himself, as some may have been written by his followers. One work that is generally credited to Hippocrates contains one of the first statements on medical ethics. In Epidemics I, in the midst of instructions on how to diagnose various illnesses, Hippocrates offers the following, “As to diseases, make a habit of two things—to help and not to harm.”

The most famous ethical work—although the exact origin of the text is unknown—is the Hippocratic Oath. In eight paragraphs, those swearing the oath pledge to “keep [patients] from harm and injustice.” The oath also requires physicians to give their loyalty and support to their fellow physicians, promise to apply dietetic measures for the benefit of the sick, refuse to provide abortion or euthanasia (the act of assisting a chronically ill person to die), and swear not to make improper sexual advances against any members of the household. “In purity and holiness I will guard my life and my art,” concludes one section of the oath. For most of the 20th century, it was common for modified versions of the Hippocratic Oath to be recited by medical students upon the awarding of their degrees. For many people, the oath still symbolizes a physician’s duties and obligations.

The idea of ethical conduct is common in many early texts, including those from ancient India and China—cultures in which medical knowledge was viewed as divine or magical in origin. Echoing the Hippocratic Oath, the Caraka Samhita, a Sanskrit text written in India roughly 2,000 years ago, urges the following commandment to physicians, “Day and night, however you may be engaged, you shall strive for the relief of the patient with all your heart and soul. You shall not desert the patient even for the sake of your life or living.” Similar sentiments can be found in the Chinese text Nei Jing (The Yellow Emperor's Classic of Inner Medicine), dating from the 2nd century bc. This work stressed the connection between virtue and health. Three centuries later, the work of the Chinese physician Sun Simiao emphasized compassion and humility, “...a Great Physician should not pay attention to status, wealth, or age.... He should meet everyone on equal ground....”

In Europe during the Middle Ages, the ethical standards of physicians were put to the test by the bubonic plague, the highly contagious Black Death that arrived around the mid-1300s and remained a threat for centuries. When plague broke out, physicians had a choice: They could stay and treat the sick—risking death in the process—or flee. The bubonic plague and other epidemics provide an early example of the challenges that still exist today when doctors must decide whether they are willing to face personal risks when caring for their patients.

By the 18th century, particularly in Britain, the emphasis in medical ethics centered on proper, honorable behavior. One of the best-known works from the period is Medical Ethics; or, a Code of Institutes and Precepts, Adapted to the Professional Conduct of Physicians and Surgeons, published in 1803 by the British physician Thomas Percival. In his 72 precepts, Percival urged a level of care and attention such that doctors would “inspire the minds of their patients with gratitude, respect, and confidence.” His ethics, however, also permitted withholding the truth from a patient if the truth might be “deeply injurious to himself, to his family, and to the public.” At roughly the same time American physician Benjamin Rush, a signer of the Declaration of Independence, was promoting American medical ethics. His lectures to medical students at the University of Pennsylvania in Philadelphia, spoke of the virtues of generosity, honesty, piety, and service to the poor.

By the early 19th century, it seemed that such virtues were in short supply, and the public generally held physicians in North America in low esteem. Complicating the problem was the existence of a variety of faith healers and other unconventional practitioners who flourished in an almost entirely unregulated medical marketplace. In part to remedy this situation, physicians convened in 1847 to form a national association devoted to the improvement of standards in medical education and practice. The American Medical Association (AMA), as the group called itself, issued its own code of ethics, stating, “A physician shall be dedicated to providing competent medical service with compassion and respect for human dignity. A physician shall recognize a responsibility to participate in activities contributing to an improved community.” This text was largely modeled on the British code written by Percival, but it added the idea of mutually shared responsibilities and obligations among doctor, patient, and society. Since its creation, the AMA Code has been updated as challenging ethical issues have arisen in science and medicine. The code now consists of seven principles centered on compassionate service along with respect for patients, colleagues, and the law. The Canadian Medical Association (CMA), established in 1867, also developed a Code of Ethics as a guide for physicians. Today the CMA code provides over 40 guidelines about physician responsibilities to patients, society, and the medical profession.

In recent years, however, the field of medical ethics has struggled to keep pace with the many complex issues raised by new technologies for creating and sustaining life. Artificial-respiration devices, kidney dialysis, and other machines can keep patients alive who previously would have succumbed to their illnesses or injuries. Advances in organ transplantation have brought new hope to those afflicted with diseased organs. New techniques have enabled prospective parents to conquer infertility. Progress in molecular biology and genetics has placed scientists in control of the most basic biochemical processes of life. With the advent of these new technologies, codes of medical ethics have become inadequate or obsolete as new questions and issues continue to confront medical ethicists.

III

How Are Ethical Decisions Made in Medicine?

Throughout history the practice of medical ethics has drawn on a variety of philosophical concepts. One such concept is deontology, a branch of ethical teaching centered on the idea that actions must be guided above all by adherence to clear principles, such as respect for free will. In contemporary bioethics, the idea of autonomy has been of central importance in this tradition. Autonomy is the right of individuals to determine their own fates and live their lives the way they choose, as long as they do not interfere with the rights of others. Other medical ethicists have championed a principle known as utilitarianism, a moral framework in which actions are judged primarily by their results. Utilitarianism holds that actions or policies that achieve good results—particularly the greatest good for the greatest number of people—are judged to be moral. Still another philosophical idea that has been central to medical ethics is virtue ethics, which holds that those who are taught to be good will do what is right.

Many medical ethicists find that these general philosophical principles are abstract and difficult to apply to complex ethical issues in medicine. To better evaluate medical cases and make decisions, medical ethicists have tried to establish specific ethical frameworks and procedures. One system, developed in the late 1970s by the American philosopher Tom Beauchamp and the American theologian James Childress, is known as principlism, or the Four Principles Approach. In this system ethical decisions pertaining to biomedicine are made by weighing the importance of four separate elements: respecting each person’s autonomy and their right to their own decisions and beliefs; the principle of beneficence, helping people as the primary goal; the related principle of nonmalificence, refraining from harming people; and justice, distributing burdens and benefits fairly.

Medical ethicists must often weigh these four principles against one another. For example, all four principles would come into play in the case of a patient who falls into an irreversible coma without expectation of recovery and who is kept alive by a mechanical device that artificially maintains basic life functions such as heartbeat and respiration. The patient’s family members might argue that the patient, if able to make the decision, would never want to be sustained on a life-support machine. They would argue from the viewpoint of patient autonomy—that the patient should be disconnected from the machine and allowed to die with dignity. Doctors and hospital staff, meanwhile, would likely be concerned with the principles of beneficence and nonmalificence—the fundamental desire to help the patient or to refrain from harmful actions, such as terminating life support. Consulting on such a case, the medical ethicist would help decide which of these conflicting principles should carry the most weight. An ethicist using principlism might work toward a solution that addresses both sides of the conflict. Perhaps the family and medical staff could agree to set a time limit during which doctors would have the opportunity to exhaust every possibility of cure or recovery, thus promoting beneficence. But at the end of the designated period, doctors would agree to terminate life support in ultimate accordance with the patient’s autonomy.

Although some medical ethicists follow principlism, others employ a system known as casuistry, a case-based approach. When faced with a complex bioethical case, casuists attempt to envision a similar yet clearer case in which virtually anyone could agree on a solution. By weighing solutions to the hypothetical case, casuists work their way toward a solution to the real case at hand.

Casuists might confront a case that involves deciding how much to explain to a gravely ill patient about his or her condition, given that the truth might be so upsetting as to actually interfere with treatment. In one such case cited by American ethicist Mark Kuczewski from the Center for the Study of Bioethics at the Medical College of Wisconsin in Milwaukee, a 55-year-old man was diagnosed with the same form of cancer that had killed his father. After a surgical procedure to remove the tumor, the patient’s family members privately told his doctors that if the patient knew the full truth about his condition, he would be devastated. In weighing this matter, a casuist might envision a clear-cut case in which a patient explicitly instructs doctors or caregivers not to share any negative information about prospects for cure or survival. The opposite scenario would be a case in which the patient clearly wishes to know every bit of diagnostic information, even if the news is bad. The challenge for the casuist is to determine which scenario, or paradigm, most closely resembles the dilemma at hand, and, with careful consideration of the case, try to proceed from the hypothetical to a practical solution. In this particular case, the cancer patient was informed that his tumor had not been successfully removed and that more curative measures were called for. His treatments continued. In the end, however, he died of the disease without ever being told of a terminal diagnosis.

IV

Current Medical Ethics Issues

Casuistry and principlism are just two of many bioethical frameworks. Each approach has its proponents, and volleys of disagreement and debate frequently fly among the various schools of thought. Yet each approach represents an attempt to deal with thorny, conflicting issues that commonly arise in the complex and contentious arena of medicine. These issues can include the rights and needs of the patient, who may, for example, decide to discontinue treatment for a life-threatening illness, preferring to die with dignity while still mentally competent to make that choice. There is the obligation of the doctor, whose duty it is to save and prolong life. There is the hospital or health-care system, whose administrators must weigh the obligation to sustain life against the often-enormous expense of modern medical methods. And there is the law, which seeks to protect citizens from harm while at the same time respecting autonomy. The remainder of this article discusses some of the most prominent dilemmas and decisions faced by modern medical ethicists.

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