Medical Ethics (Encyclopedia of Nursing & Allied Health)
Medical ethics refers to the discussion and application of moral values and responsibilities in the areas of medical practice and research. While questions of medical ethics have been debated since the beginnings of Western medicine in the fifth century B.C., medical ethics as a distinctive field came into prominence only since World War II. This change has come about largely as a result of advances in medical technology, scientific research, and telecommunications. These developments have affected nearly every aspect of clinical practice, from the confidentiality of patient records to end-of-life issues. Moreover, the increased involvement of government in medical research as well as the allocation of health care resources brings with it an additional set of ethical questions.
The Hippocratic tradition
Medical ethics generally traces its origins to the ancient Greek physician Hippocrates (46077 BC), who is credited with defining the first ethical standard in medicine: "Do no harm." The oath attributed to Hippocrates was traditionally recited by medical students as part of their medical school's graduation ceremonies. A modernized version of the Hippocratic Oath that has been approved by the American Medical Association (AMA) reads as follows:
You do solemnly swear, each by whatever he or she holds most sacred
That you will be loyal to the Profession of Medicine and just and generous to its members
That you will lead your lives and practice your art in uprightness and honor
That into whatsoever house you shall enter, it shall be for the good of the sick to the utmost of your power, your holding yourselves far aloof from wrong, from corruption, from the tempting of others to vice
That you will exercise your art solely for the cure of your patients, and will give no drug, perform no operation, for a criminal purpose, even if solicited, far less suggest it
That whatsoever you shall see or hear of the lives of men or women which is not fitting to be spoken, you will keep inviolably secret
These things do you swear. Let each bow the head in sign of acquiescence
And now, if you will be true to this your oath, may prosperity and good repute be ever yours; the opposite, if you shall prove yourselves forsworn.
Religious traditions and medical ethics
Ancient Greece was not the only premodern culture that set ethical standards for physicians. Both Indian and Chinese medical texts from the third century B.C. list certain moral virtues that practitioners were to exemplify, among them humility, compassion, and concern for the patient's well-being. In the West, both Judaism and Christianity gave extensive consideration to the importance of the physician's moral character as well as his duties to patients. In Judaism, medical ethics is rooted in the study of specific case histories interpreted in the light of Jewish law. This case-based approach is known as casuistry. In Christianity, ethical reflection on medical questions has taken the form of an emphasis on duty, moral obligation, and right action. In both faiths, the relationship between the medical professional and the patient is still regarded as a covenant or sacred bond of trust rather than a business contract. In contemporary Buddhism, discussions of medical ethics reflect specifically Buddhist understandings of suffering, the meaning of human personhood, and the significance of death.
The Enlightenment and the nineteenth century
The eighteenth century in Europe witnessed a number of medical as well as general scientific advances, and the application of scientific principles to medical education led to a new interest in medical ethics. The first book on medical ethics in English was published by a British physician, Thomas Percival, in 1803. In the newly independent United States, Benjamin Rush signer of the Declaration of Independence as well as a physicianectured to the medical students at the University of Pennsylvania on the importance of high ethical standards in their profession. Rush recommended service to the poor as well as the older Hippocratic virtues of honesty and justice.
In the middle of the nineteenth century, physicians in the United States and Canada began to form medical societies with stated codes of ethics. These codes were drawn up partly because there was no government licensing of physicians or regulation of medical practice at that time. The medical profession felt a need to regulate itself as well as set itself apart from quacks, faith healers, homeopaths, and other practitioners of what would now be called alternative medicine. The AMA, which was formed in 1847, has revised its Code of Ethics from time to time as new ethical issues have arisen. The present version consists of seven principles. The Canadian Medical Association (CMA) was formed in 1867 and has a Code of Ethics with 40 guidelines for the ethical practice of medicine.
Theoretical approaches to medical ethics
PHILOSOPHICAL FRAMEWORKS. Since the early Middle Ages, questions of medical ethics have sometimes been discussed within the framework of specific philosophical positions or concepts. A follower of Immanuel Kant (1724804), for example, would test an ethical decision by the so-called categorical imperative, which states that one should act as if one's actions would serve as the basis of universal law. Another philosophical position that sometimes appears in discussions of medical ethics is utilitarianism, or the belief that moral virtue is based on usefulness. From a utilitarian perspective, the best decision is that which serves the greatest good of the greatest number of people. An American contribution to philosophical approaches to medical ethics is pragmatism, which is the notion that practical results, rather than theories or principles, provide the most secure basis for evaluating ethical decisions.
CASUISTRY. Casuistry can be defined as a case-based approach to medical ethics. An ethicist in this tradition, if confronted with a complicated ethical decision, would study a similar but simpler case in order to work out an answer to the specific case under discussion. As has already been mentioned, casuistry has been used as a method of analysis for centuries in Jewish medical ethics.
THE "FOUR PRINCIPLES" APPROACH. Another approach to medical ethics was developed in the 1970s by a philosopher, Tom Beauchamp, and a theologian, James Childress, who were working in the United States. Beauchamp and Childress drew up a list of four principles that they thought could be weighed against one another in ethical decision-making in medicine. The four principles are:
- the principle of autonomy, or respecting each person's right to make their own decisions
- the principle of beneficence, or doing good as the primary goal of medicine
- the principle of nonmaleficence, or refraining from harming people
- the principle of justice, or distributing the benefits and burdens of a specific decision fairly
One limitation of the "Four Principles" approach is that different persons involved in an ethical decision might well disagree about the relative weight to be given to each principle. For example, a patient who wants to be taken off a life-support system could argue that the principle of autonomy should be paramount, while the clinical staff could maintain that the principles of beneficence and nonmaleficence are more important. The principles themselves do not define or imply a hierarchical ranking or ordering.
Current issues in medical ethics
One well-known writer in the field of medical ethics has recently written an article listing what he considers "cutting-edge" topics in medical ethics. While space does not permit discussion of these subjects here, they serve as a useful summary of the impact of technology and globalization on medical ethics in the new millennium:
- End-of-life care. Medical advances that have led to a dramatic lengthening of the life span for adults in the developed countries and a corresponding increase in the elderly population have made end-of-life care a pressing issue.
- Medical error. The proliferation of new medications, new surgical techniques, and other innovations means that the consequences of medical errors are often very serious. All persons involved in health care have an ethical responsibility to help improve the quality of care.
- Setting priorities. The fair allocation of health care resources is one example of setting priorities.
- Biotechnology. Medical ethicists are still divided over the legitimacy of stem cell research, cloning, and other procedures that advances in biotechnology have made possible.
- "eHealth." The expansion of the Internet and other rapid changes in information technology have raised many questions about the confidentiality of electronic medical records as well as the impact of online education on medical training.
- Global bioethics. Global bioethics represents an attempt to consider the ethical problems confronting the poorer countries of the world, rather than concentrating on medical issues from the perspective of the wealthy countries. Of the 54 million deaths that occur each year around the world, 46 million occur in lowand middle-income countries.
One implication for physicians is the importance of studying ethical issues during one's professional education. Many medical, dental, and nursing schools now include courses in their curricula that deal with such topics as moral decision-making, definitions of life and death, the ethical complexities of professional-patient relationships, and the moral safeguards of medical research. As of 2000, more than 25 universities in the United States and Canada offer graduate degrees in medical ethics.
A second implication is recognizing the necessity of interdisciplinary conversation and cooperation. Physicians can benefit from the insights of scholars in the social sciences, philosophy, theology, law, and history. At the same time, they have much to offer professionals in other fields on the basis of their clinical experience.
Casuistry case-based approach to medical ethics.
Categorical imperativehe principle that one should act in such a way that one's deeds could become universal rules of conduct.
Ethics system or set of moral principles; also, the study of values relating to human conduct.
Hippocratic Oathhe ethical oath attributed to Hippocrates that is used as a standard for care by physicians worldwide.
Pragmatism philosophical position that regards practical results, rather than abstract principles or theories, as the essential criterion of moral value.
Utilitarianismn ethical position based on the premise that usefulness is the best measure of moral worth, and that ethical decisions should promote the good of the largest number of persons.
Brody, Baruch A., et al. Medical Ethics: Codes, Opinions, and Statements. New York: BNA Books, 2000.
Burkhardt, Margaret A., and Alvita K. Nathaniel. Ethics and Issues in Contemporary Nursing. Albany, NY: Delmar Publishers, 1998.
Davis, Anne J., et al. Ethical Dilemmas and Nursing Practice. Paramus, NJ: Prentice Hall, 1996.
Dubler, Nancy N. "Legal and Ethical Issues." The Merck Manual of Geriatrics. 2nd ed. Whitehouse Station, NJ: Merck Research Laboratories, 2000.
Hughes, James J., and Damien Keown. "Buddhism and Medical Ethics: A Bibliographic Introduction." Journal of Buddhist Ethics 7 (2000): 1-12.
Sabatini, Margaret M. "Health Care Ethics: Models of the Provider-Patient Relationship." Dermatology Nursing (June 1998): 201-206.
Singer, Peter A. "Medical Ethics (Clinical review)." British Medical Journal 321 (July 29, 2000): 282-285.
Wolinsky, Howard. "Steps Still Being Taken to Undo Damage of 'America's Nuremberg.'" Annals of Internal Medicine (August 15, 1997).
American Medical Association, Council on Ethical and Judicial Affairs. 535 North Dearborn St., Chicago, IL60610. (312) 645-5000.
American Nurses Association. 600 Maryland Ave. SW, Ste. 100 West, Washington, DC 20024. (800) 274-4262. <<a href="http://www.nursingworld.org">http://www.nursingworld.org>.
American Society of Bioethics and Humanities. 4700 W. Lake, Glenview, IL 60025. (847) 375-4745. <<a href="http://www.asbh.org">http://www.asbh.org>.
Canadian Medical Association. 1867 Alta Vista Drive, Ottawa ON K1G 3Y6. (613) 731-8610 x2307 or (888) 855-2555. Fax (613) 236-8864. .
Institute for Jewish Medical Ethics. Hebrew Academy of San Francisco, San Francisco, CA. (415) 752-7333 or (800) 258-4427. <<a href="http://www.ijme.org">http://www.ijme.org>.
National Bioethics Advisory Commission. 6705 Rockledge Drive, Suite 700, Rockville, MD 20892. (310) 402-4242. <<a href="http://www.bioethics.gov">http://www.bioethics.gov>.
Canadian Medical Association. Code of Ethics of the Canadian Medical Association. Policy statement approved by the CMA Board of Directors, October 15, 1996.
Ken R. Wells
Medical Ethics (Encyclopedia of Science and Religion)
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
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Callahan, Daniel. "The Sanctity of Life." In Updating Life and Death: Essays in Ethics and Medicine, ed. Donald R. Cutler. Boston: Beacon Press, 1969.
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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.
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Sandel, Michael. Democracy's Discontent: America in Search of a Public Philosophy. Cambridge, Mass.: Harvard University Press, 1996.
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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