Medical ethics, an offspring of the field of ethics, shares many basic tenets with its siblings: nursing ethics, pharmaceutical ethics, and dental ethics. The definition of medical ethics is itself an issue of some controversy. The term is used to describe the body of literature and instructions prescribing the broader character ideals and responsibilities of being a doctor. Recent sociopolitical and technological changes, however, have meant that medical ethics is also involved with biomedical decision making and patients’ rights.
In the first sense of the term, medical ethics consists of professional and character guidelines found in codes and charters of ethics (e.g., the American Medical Association Code of Medical Ethics); principles of ethics (e.g., autonomy, beneficence, nonmaleficence, and justice); and oaths (e.g., the Hippocratic Oath). These formal declarations have the combined effect of expressing an overlapping consensus, or majority view, on how all physicians should behave. It is common to find additional heightened requirements for certain specialties in medicine, such as psychiatry, pain medicine, and obstetrics and gynecology. Moreover, these ethical norms tend periodically to shift as the responsibilities of good doctoring change over time. Such shifts can give rise to heated debates, especially when individuals maintain certain values that have been modified or rejected by the majority.
For example, in the 1980s, the medical profession was forced to consider doctors’ obligations in treating HIV/AIDS patients in a climate of discrimination. The American Medical Association (AMA) promulgated ethical rules requiring that physicians treat HIV/AIDS patients whose condition is within the physician's realm of competence. When such rules are violated, boards of medicine, medical associations, hospital and medical school committees, and other credentialing agencies have the difficult task of reviewing alleged breaches and sanctioning misconduct. These professional guidelines begin to clarify the boundaries and goals of medicine as a social good. They attempt to ensure that medical practitioners act humanely as they fight and prevent diseases, promote and restore health, and reduce pain and suffering. The ethical customs found in codes, charters, principles, and oaths form the basis of an entire culture of medicine within the profession.
The practice of medicine is bound by ethical rules for an important reason. In order to fulfill their healing obligation, medical practitioners must often engage in risky procedures interfering with the bodies and minds of vulnerable individuals. Bodily interference, if unconstrained by certain legitimate guiding rules, can be nothing more than assault and battery. Patients must be assured that they will benefit from—or at least not be harmed by—a doctor's care. The establishment of trust is crucial to this end, and once earned, trust marks the doctor–patient relationship.
Perhaps one of the most enduring doctrines in the history of medical ethics is the Hippocratic Oath. The oath dates back to the fourth century b.c.e. and forms the basis of Western medical ethics. It reflects the assumed values of a brotherhood of physicians who charge themselves to care for the sick under a pledge witnessed by the Greek deities. Of great interest to doctors at the time was distinguishing the genuine physician from the fraudulent practitioner. One way in which the oath furthers this goal is by prizing teachers and teaching, requiring that the physician hold his teacher in the “art” of medicine on par with his own parents. It also requires the physician to pledge to help the sick according to his skill and judgment and never do harm to anyone, never administer a deadly drug even when asked to do so, never induce abortion, and never engage in intentional misdeeds with patients (sexual or otherwise). It further requires the physician to keep secret all those things that ought not be revealed about his patients. The good physician, the oath concludes, may enjoy a good life and honored reputation, but those who break the oath shall face dishonor.
To this day, most graduating medical school students swear to some version of the Hippocratic Oath, usually one that is gender-neutral and that departs somewhat from the traditional prohibitions. The mandate of the oath is strong; it directs practitioners to desire what is best for the health of patients. A growing number of physicians and ethicists realize, however, that the Hippocratic Oath and similar ethical codes, though motivational, are inadequate in dealing with the novelties of current practice.
Medicine has recently undergone radical shifts in the scientific, technological, economic, social, and political realms, giving rise to artificial life-sustaining devices and treatments, legalized abortions, new artificial reproductive technologies, inventive cosmetic surgeries, stem cell and gene therapies, organ transplantation, palliative care, physician-assisted suicide, and conflicts of interest more powerful than anyone could have predicted just a few decades ago. Many matters previously thought of as “human nature” are continuously being recharacterized to reflect changing knowledge, scientific and otherwise. Medical ethics engages these debates and evaluates the correlative concerns over the definition of death, the moral status of the fetus, the boundaries of procreation and parenting, the flexibility of the concept of personhood, the rights of the dying, and the role of corporations in medicine.
Although physicians’ codes play a crucial role in defining the broad parameters of ethical conduct in medicine, in the last few decades sociopolitical demands and market forces have played a much larger role in both shaping and complicating ethics in medicine. Medical ethics then becomes a tool for critical reflection on modern biomedical dilemmas. Ethics scholars and clinical ethicists are regularly consulted when principles or codes appear inadequate because they prescribe unclear, conflicting, or unconscionable actions. Even for ethicists, it is not always obvious what “doing the right thing” means; however, many ethical dilemmas in medicine can be deconstructed using the theoretical tools of medical ethics and sometimes resolved by encouraging decision makers to consider the merits, risks, and psychosocial concerns surrounding particular actions or omissions.
To be sure, clinical ethicists usually do not unilaterally declare right and wrong. But they can ensure that all rightful parties have a fair and informed voice in the discussion of ethically sensitive matters. Medical ethics, as a clinical discipline, approaches decision making through formal processes (e.g., informed consent) and traditional theories (e.g., utilitarianism) that can enhance medical and ethical deliberation. The need for these processes and theories was not just a by-product of technological advances but also a consequence of a movement that has recharacterized the civil status of doctors and patients.
The American Civil Rights Movement of the 1950s and 1960s brought previously denied freedoms to people of color and reinvigorated the spirit of free choice. The unconscionable inferior treatment of marginalized groups was the subject of great sociopolitical concern. Significant legal and moral changes took place both in the ideology surrounding the concepts of justice and equality and in the rigidity of hierarchies found in established institutions of status such as churches, families, schools, and hospitals. Out of the movement came a refreshing idea of fundamental equality based on the dignity of each individual. In the decades that followed, strong criticism arose against paternalism—the practice of providing for others’ assumed needs in a fatherly manner without recognizing individuals’ rights and responsibilities. It was no longer acceptable for all-knowing physicians to ignore the preferences and humanity of patients while paternalistically doing what they thought was in their “best interests.” Doctors were required to respect patients’ autonomy, or ability to govern themselves. With this recognition came a general consensus that patients have the legal and ethical right to make uncoerced medical decisions pertaining to their bodies based on their own values.
Autonomy, now viewed by many as a basic principle of biomedical ethics, often translates in practice into the process of “informed consent.” Full informed consent has the potential to enrich the doctor–patient relationship by requiring a competent patient and a physician to engage in an explanatory dialogue concerning proposed invasive treatments. By law, physicians must presume that all patients are competent to make medical decisions unless they have a valid reason to conclude otherwise. If a patient is diagnosed as incapable of consenting, the patient's surrogate decision maker or “living will” should be consulted, assuming they are available and no other recognized exception applies. At its core, informed consent must involve the discussion of five elements:
the nature of the decision or procedure
the reasonable alternatives to the proposed intervention
the relevant risks, benefits, and uncertainties related to each alternative
an assessment of patient understanding
the acceptance of the intervention by the patient
A physician's failure to abide by this decision process can lead to ethical and legal sanctions.
Scholarly questions often arise regarding the diagnosis of incapacity, the determination of how much information must be shared, the definition of “understanding,” and the established exceptions to informed consent (e.g., emergency, patient request not to be informed, and “therapeutic privilege”). It is important for informed consent to be an interactive process and not merely the signing of boilerplate forms. The latter does not take the interests of patients into account, it does not further the doctor–patient relationship, and it can result in future conflict or uncertainty if previously competent patients become incapacitated.
In addition to doctors, many other parties are involved in caring for the ill and facilitating medical decision making. Relatives, spiritual counselors, nurses, social workers, and other members of the health care team all help identify and satisfy the vital needs of patients. Informed consent is a process that can give rise to meaningful dialogue concerning treatment, but like some other tools of practical ethics, it alone may not provide the intellectual means for deeper reflection about values and moral obligations.
To this end, medical ethics makes use of many foundational theories that help situate values within wider frameworks and assist patients, families, and doctors with making ethical choices. These moral theories are typically reduced to three categories: the deontological (duty-based, emphasizing motives and types of action); the consequentialist (emphasizing the consequences of actions); and the virtue-based (emphasizing excellence of character and aspiration for the good life).
The most influential deontological theory is that of Immanuel Kant (1724–1804). Kant derived certain “categorical imperatives” (unconditional duties) that, in his view, apply to the action of any rational being. Generally speaking, the relevant imperatives are as follows: first, individuals have a duty to follow only those subjective principles that can be universalized without leading to some inconsistency and, second, individuals must treat all rational beings as “ends in themselves,” respectful of the dignity and integrity of the individual and never merely treating them as a means to some other end. Despite some philosophical criticism, Kant's revolutionary thoughts on the foundations of morality and autonomy are still very timely.
In contrast to Kantian deontology, an influential consequentialist theory is utilitarianism, which states that the moral worth of an action is determined solely by the extent to which its consequences maximize “utility.” For Jeremy Bentham (1748–1832), utility translates into “pleasure and the avoidance of pain”; for John Stewart Mill (1806–1873), utility means “happiness.” Utilitarianism offers another popular way to conceptualize right and wrong, but it gives rise to the often asked question of how one might accurately calculate the tendency to maximize happiness.
Finally, virtue-based ethics, principally attributed to the Greek philosophy of Plato and Aristotle, generally holds that a person of good character strives to be excellent in virtue, constantly aiming for the telos or goal of greater happiness. In leading a virtuous life, the individual may gain both practical and moral wisdom.
These three basic ethical frameworks maintain their relevance today, inspiring many complementary models of ethical reasoning. For example, medical ethics has benefited significantly from scholarship in theological, feminist, communitarian, casuistic, and narrative ethics. These perspectives either critically analyze or combine the language of deontology, consequentialism, and virtue. Together, theories of ethics and their descendants provide some further means of deconstructing the ethically difficult cases in medicine, giving us the words to explore our moral intuitions.
Medical ethics is now often described within the somewhat broader context of bioethics, a burgeoning field concerned with the ethics of medical and biological procedures, technologies, and treatments. Although medical ethics is traditionally more confined to issues that arise in the practice of medicine, both bioethics and medical ethics engage with significant overlapping questions. What are the characteristics of a “good” medical practitioner? What is the best way to oversee the use and distribution of new medical technologies and therapies that are potentially harmful? Who should have the right and responsibility to make crucial moral medical decisions? What can individuals and governments do to help increase access, lower cost, and improve quality of care? And how can individuals best avoid unacceptable harm from medical experimentation? Patients, doctors, hospital administrators, citizens, and members of the government are constantly raising these questions. They are difficult questions, demanding the highest level of interdisciplinary collaboration.
In sum, since the days of Hippocrates, the medical profession has tried to live by the principle of primum non nocere (first do no harm). This principle has been upheld by many attentive professionals but also betrayed by some more unscrupulous doctors. To stem potential abuses offensive to human dignity and social welfare, medical ethicists carefully consider the appropriateness of new controversial medical acts and omissions. They try to ensure that medical decision makers do not uncritically equate the availability of certain technoscientific therapies and enhancements with physical and psychosocial benefit. Doctors and patients can participate in a better-informed medical discourse if they combine the dictates of professional rules with procedural formalities of decision making, respecting the diversity of values brought to light. Through this deliberative process, individuals will be able to come closer to understanding their responsibilities while clarifying the boundaries of some of the most difficult questions of the medical humanities.
See also Eugenics; Human Genome Project; Medical Marijuana; Reproductive Technology; Stem Cell Research; Abortion (vol. 3); Euthanasia and Physician-Assisted Suicide (vol. 3)
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