Moral concerns have always been implicit in medicine. Indeed, the division between science and valueshe objectivity sought in the study of nature and the values governing human behaviorisappears at the bedside. The medical choices made by physicians and their patients must, by their very nature, reflect a complex array of values that determine how the findings of clinical science and the applications of their associated technologies are to be deployed in the care of the ill. Thus medicine necessarily obscures the line separating science and human values because of the intimate connection between clinical science and its object of study and intervention: the personhe nexus of politico-judicial action, moral agency, scientific scrutiny, and religious sanctification.
The origins of contemporary medical ethics may be traced to the Enlightenment, when the science of morals and the morals of science became the subject of intense deliberation, and from which medical ethics arose as a system of mutually related contracts between doctor and patient (Haakonssen 1997). But an even older religious traditionatholic (Kelly 1979), Protestant (Fletcher 1954), and Jewish ( Jakobovits 1959)as debated the moral implications of modern medicine generally, and in particular, since the mid-twentieth century, those matters arising in consequence of clinical interventions that challenged dogma about life and death, including abortion, terminal care, genetic counseling, and the like. But medical ethics in its present formhilosophical, secular, legalistic, and professionalizedas had a brief history.
During the late 1960s, medical ethics burst forth into the political arena. Rapid technological advances brought new challenges to the very definition of life and death. This in itself would have initiated speculations over how such new-found scientific power should be utilized. In addition, a massive social realignment was underway under the auspices of a renewed commitment to civil and human rights. Focused upon various forms of paternalism, particularly heated debates about informed consent for therapy, protection of subjects enrolled in human research, and recourse to medical malpractice, stimulated both a reexamination of the ethics underlying these issues as well as a more general discussion of medicine's moral philosophy and legal standing (Rothman 1991; Jonsen 1995). Soon, medical ethics became a formal discipline, replete with institutes, journals, books, conferences, and professionals devoted to what had heretofore been a subject reserved for religious contemplation.
Definitions and distinctions
Medical ethics may be defined as the discourse that seeks to define moral guidelines for the care of patients. Within this discipline, a distinction must be drawn between judicial medical ethics and philosophical medical ethics. In the former, medical ethics comprises rules or procedures established by governing agencies and the courts meant to guide decision-making in difficult areas like abortion, for example, or the involuntary commitment of a psychotic patient. In this context, medical ethics implicitly informs the legal directives, and "risk management," the distillation of this discourse, defines the procedures hospitals and health care professionals follow to minimize their legal liability. On the other hand, philosophical medical ethics has no proscribed rules, only a tradition of offering philosophical or theological perspectives to ethical dilemmas and proposing possible answers. Thus, diverse matters ranging from informed consent to end of life issues to new technological opportunities (e.g., artificial insemination) may be addressed at these two levels, the judicial and the philosophical: What, on the basis of the law, is the correct procedure for dealing with a clinical predicament? or, alternatively, What are the secular ethical or religious principles that offer ways of thinking about a morally ambiguous problem? Judicial medical ethicsractical instructions, rules, regulations, contracts, and ultimately the laway be distilled from such philosophical deliberations, and these, together with judicial precedent and political considerations ultimately result in accepted practice. In short, although the law is the final arbiter of practice, philosophical ideas impact on the shape of social policy.
This entry will consider "medical ethics" solely in its philosophical mode. It is around this topic that one can most clearly discern how theologians, poised and ready to participate in a discourse they had already developed for their own purposes, offer insights (and ideologies) from their rich intellectual and religious heritage in order to influence the development of contemporary judicial and philosophical medical ethics (Lammers and Verhay 1987; Verhay and Lammers 1993; Camenisch 1994).
The competition of moral principles
Medicine reflects broad social values, and American multiculturalism has demanded a mixture of ethical precepts from diverse sources. In the end, citizens live together under a common law, one that seeks to satisfy the pluralistic demands of contemporary life and still remain faithful to the older core of foundational principles. Since at least World War II, America has developed a rights-based culture that endeavors to respect the autonomy of its citizens and thereby to enhance their ability to enjoy life's pursuits offered by the opportunities afforded by civil equality and respect for differences in religion, race, sexual orientation, and a whole host of differentiating characteristics (Sandel 1995). American medicine has been caught in this vast social experiment stimulated by cultural diversity and unified by constitutional law.
So when medical ethicists ponder, "Under what circumstances are particular ethical responses evoked?" or "What are the ethical implications of those ethical choices?" their answers draw upon a complex array of moral principles forged together from various religious traditions and secular moral philosophies. Given the current dominant legal and political culture based upon the protection of individual rights, autonomy as a governing philosophical principle has been prioritized in medical ethics. For, as noted above, in the process of deliberating medical ethics, philosophers consider the practical application of their studies, and these are, in a sense, over-determined by legal interpretation, one focused on rights. Thus, in the judicial context, medical ethics is like a lopsided table with five legs: Although autonomy, beneficence, justice, utilitarianism, and non-malfeasance each claim consideration, autonomy usually trumps other contenders (Beauchamp and Childress 2001). This dominance has been widely regarded as both a judicial and philosophical problem.
Autonomy draws on two understandings of freedom (Berlin 1969): One is negative, the freedom from oppression or interference by another, and the second is positive, the freedom to participate in the process by which one's life is controlled. In the research setting, autonomy in the form of informed consent is the governing principle that protects human research subjects from hidden manipulation (Belmont Report 1979). And while in the clinic and the hospital, similar rules of informed consent operate, a rights-based morality makes little attempt to articulate the ethics of other dimensions of the doctor-patient relationship. And here we discover an ambiguous moral construction lying at the foundation of medical care.
Indisputably, autonomy serves a vital judicial-legal function in our system of medical law, and this may well account for its continued importance, but it is more likely that the moral depth of our notions of respect for persons reflects a still deeper commitment to Western religious roots (Downie and Telfer 1969; Thomasma 1984; Engelhardt 1996). Our care of the ill is based on a deep metaphysical sense of response to the other, a reaction that generates response-ibility (Tauber 1999). This ethical metaphysics is essentially a theological assertion, not a philosophical one. This position was first espoused by the early founders of American medical ethics, Joseph Fletcher (1954) and Paul Ramsey (1970). They championed autonomy, because this principle reflected their basic humanitarianism as theologians ( Jonsen 1998). But autonomy had little philosophical support in their writings, where it served as a placeholder for a humane medicine, one that held the sanctity of life paramount. Indeed, by not delineating how autonomy was in competition with other moral tenets, these early discussions inadvertently obfuscated the complexity of medicine's moral universe.
Physicians and nurses assume responsibility for the care of their patients, and the "moral space" in which patients reside is not necessarily coincident with that of autonomous citizens. Autonomy is inadequate, by itself, to account for medicine's moral calling because of two failings. First, from the patient's perspective, the notion of autonomy is frequently distorted in the clinical setting (Schneider 1998; Tauber 2001). Patients necessarily relinquish their full autonomy to experts, and in this regard, they cannot make truly autonomous, self-reliant, fully informed decisions, and must instead ultimately rely on the competence and good will of their health-care providers to represent their best interests. Second, autonomy as a construct cannot account for the ethical responsibilities of the caregiver (Tauber 1999). The sense of responsibility exhibited by physicians and nurses arises from their sense of care for others, not primarily from a set of rules designed to protect patient autonomy. Respect for the person in this setting is implicit to their professional role, a role characterized by a profound sense of commitment to their charge. This ethic of compassion regards autonomy as only one of a number of moral principles governing the caring relationship, among which it finds in beneficence a more resonant expression of medicine's fundamental ethos. This is the moral principle that perhaps most obviously captures the Judeo-Christian religious ethos, the appreciation that God's work on Earth is articulated through the caring relationship between people and their respective responsibility for each other (Pelligrino and Thomasma 1988; Kultgen 1995). The foundations of social justice and much of the implicit understanding of our social mores are based on this deep moral maxim.
Thus "patients" and "citizens" are revealed as not necessarily occupying the same ethical domain. While their respective moral identities over-lap, they nonetheless are distinct. The patient, at least in the autonomy model, receives medical attention only to the extent that his or her rights as an autonomous citizen are respected. This is essentially a defensive posture, one at potential odds with those moral (ultimately religious) concerns most prominent for the doctor or nurse, whose primary ethical affiliation is to beneficence (Pelligrino and Thomasma 1988) or, in another format, responsibility (Tauber 1999).
Seeking a synthesis
Much of philosophical medical ethics has been devoted to balancing the politico-legal view of individual autonomy with other moral principles that make strong claims in the medical culture. Although (secular) autonomy and (religious) beneficence has each followed a historical and philosophical trajectory of its own, they may be reduced to a more basic formulation, a moral foundation, which, for the sake of simplicity is, "Respect for the person" (Ramsey 1970). This idea of the inalienable sanctity and dignity of every human being derives most directly from ancient themes in the Western religious culture rather than from philosophy as such, and may account for the hold of "autonomy" on Western moral sensibilities. For theologians as well as nonbelievers, the sanctity of lifessentially a religious principleemains paramount even as it was secularized into the political principle of autonomy (Callahan 1969; Jonsen 1998).
Autonomy, a relatively new moral tenet, claims a dual heritage: The first source derives from notions of Puritan personal religious responsibility and conscience, balanced against the obligations of persons to a community designed to serve God (Shain 1995); the second source, again religious in origin, arises from natural law's endowment of persons with natural rights, self-governance, and the freedom to pursue their own dictates (Schneewind 1998). This latter tributary, one we might call individualistic, grew at the expense of communal values in the development of American democracy, while European views of autonomy have more evenly balanced community interests and responsibilities (as evidenced by universal socialized health care) against autonomy-based rights in health care delivery. Consequently, in the United States, individual rights increasingly have been regarded as sacrosanct, and correspondingly the respect for persons has shifted from one centered on communal responsibilityoth the citizen's identification with the state and the state's responsibility for the citizeno one focused on autonomy in its more atomistic interpretation (Sandel 1996). And here we see how an ethos of responsibility for others ("caring") may be subordinated to a preoccupation with protecting the rights of the individual.
The seam that ties religious and secular philosophies together is not always evident, which is strong testament to the success of liberal society, but as this discussion has emphasized, conflicting moral orientations may still show signs of differing ethical perspectives straining against one another. While autonomy carries the ancient banner of life's sanctity, its contemporary secularized meaning and applications have shorn off its religious heritage, leaving its more immediate allegiances plainly in view. So when this political and judicial principle is extended to medical ethics, the law accompanies the ill to the clinic and hospital to protect citizens. Due to this legal extrapolation, the more ancient basis of the doctor-patient relationship must accommodate a superimposed orientation different in kind and purpose to an older ethic of caring. And perhaps of more concern, telling lapses in judiciary medical ethics appear as the discourse stutters when addressing the legal basis of beneficent concerns: Physician fiduciary responsibility, those duties dictated by law that translate beneficence into standards of care, are restricted only to maintaining patient confidentiality, disclosing financial conflicts of interest, and prohibiting the abandonment of patients (Rodwin 1995); Good Samaritan laws protect doctors from suits arising from non-consented care only in the most dire of circumstances; empathy has no legal basis whatsoever.
In summary, the complexity of medical ethics begs for a full hearing, to reflect both the claims of individual rights as well as the demands of a morality that fosters responsibility. In that discussion, a combination of various moral principles allows for a philosophical discourse that attempts to represent fairly diverse interests and relationships, including the challenge of accommodating different belief systems. The product of that deliberation, which must draw upon the entire Western tradition of philosophy and its handmaiden, theology, frames a perspective on, and the terms of, the never-ending debate over the most crucial nexus of human endeavor, the life and death decisions so manifest within modern medicine's power to influence, if not control.
See also ABORTION; BIOTECHNOLOGY; MEDICINE; REPRODUCTIVE TECHNOLOGY
Beauchamp, Tom L., and Childress, James F. Principles of Biomedical Ethics, 5th edition. New York: Oxford University Press, 2001.
Berlin, Isaiah. "Two Concepts of Liberty." In Four Essays on Liberty. New York: Oxford University Press, 1969.
Callahan, Daniel. "The Sanctity of Life." In Updating Life and Death: Essays in Ethics and Medicine, ed. Donald R. Cutler. Boston: Beacon Press, 1969.
Camenisch, Paul E., ed. Religious Methods and Resources in Bioethics. Dordrecht, Netherlands: Kluwer Academic, 1994.
Engelhardt, H. Tristram. The Foundations of Bioethics, 2nd edition. New York: Oxford University Press, 1996.
Fletcher, Joseph. Morals and Medicine. The Moral Problems of: The Patient's Right to Know the Truth, Contraception, Artificial Insemination, Sterilization, and Euthanasia. Princeton, N.J.: Princeton University Press, 1954.
Haakonssen, Lisbeth. Medicine and Morals in the Enlightenment: John Gregory, Thomas Percival, and Benjamin Rush. Amsterdam and Atlanta, Ga.: Rodopi, 1997.
Jakobovits, Immanuel. Jewish Medical Ethics: Comparative and Historical Study of the Jewish Religious Attitude to Medicine and Its Practice. New York: Bloch, 1959.
Jonsen, Albert R. The Birth of Bioethics. New York: Oxford University Press, 1998.
Kelly, David F. The Emergence of Roman Catholic Medical Ethics in North America: An Historical, Methodological, Bibliographical Study. New York and Toronto: Edwin Mellen Press, 1979.
Kultgen, John. Autonomy and Intervention: Parentalism in the Caring Life. New York: Oxford University Press, 1995.
Lammers, Stephen E., and Verhey, Allen, eds. On Moral Medicine: Theological Perspectives in Medical Ethics. Grand Rapids, Mich.: Eerdmans, 1987.
National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research. Washington, D.C.: Department of Health, Education, and Welfare, 1979. Distributed by the U.S. Government Printing Office.
Pelligrino, Edmund D., and Thomasma, David C. For the Patient's Good: The Restoration of Beneficence in Health Care. New York: Oxford University Press, 1988.
Ramsey, Paul. The Patient as Person: Medical and Legal Intersections. New Haven, Conn.: Yale University Press, 1970.
Rodwin, Mark A. "Strains in the Fiduciary Metaphor: Divided Physician Loyalties and the Obligations in a Changing Health Care System" American Journal of Law and Medicine 21 (1995): 24157.
Rothman, David J. Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision Making. New York: Basic Books, 1991.
Sandel, Michael. Democracy's Discontent: America in Search of a Public Philosophy. Cambridge, Mass.: Harvard University Press, 1996.
Schneewind, J. B. The Invention of Autonomy: A History of Modern Moral Philosophy. New York: Cambridge University Press, 1998.
Schneider, Carl E. The Practice of Autonomy: Patients, Doctors, and Medical Decisions. New York: Oxford University Press, 1998.
Shain, Barry Alan. The Myth of American Individualism: The Protestant Origins of American Political Thought. Princeton, N.J.: Princeton University Press, 1994.
Tauber, Alfred I. Confessions of a Medicine Man: An Essay in Popular Philosophy. Cambridge, Mass.: MIT Press, 1999.
Tauber, Alfred I. "Historical and Philosophical Reflections on Patient Autonomy." Health Care Analysis 9, no. 3 (2001): 29919.
Thomasma, David C. "The Basis of Medicine and Religion: Respect for Persons." Linacre Quarterly 47 (1984): 14250.
Verhay, Allan, and Lammers, Stephen E. eds. Theological Voices in Medical Ethics. Grand Rapids, Mich.: Eerd-mans, 1993.
ALFRED I. TAUBER
Did this raise a question for you?