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 (460–377 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—a signer of the Declaration of Independence as well as a physician—lectured 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 (1724–1804), 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—A case-based approach to medical ethics.
Categorical imperative—The principle that one should act in such a way that one's deeds could become universal rules of conduct.
Ethics—A system or set of moral principles; also, the study of values relating to human conduct.
Hippocratic Oath—The ethical oath attributed to Hippocrates that is used as a standard for care by physicians worldwide.
Pragmatism—A philosophical position that regards practical results, rather than abstract principles or theories, as the essential criterion of moral value.
Utilitarianism—An 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.
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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. <http://www.nursingworld.org>.
American Society of Bioethics and Humanities. 4700 W. Lake, Glenview, IL 60025. (847) 375-4745. <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. <firstname.lastname@example.org>.
Institute for Jewish Medical Ethics. Hebrew Academy of San Francisco, San Francisco, CA. (415) 752-7333 or (800) 258-4427. <http://www.ijme.org>.
National Bioethics Advisory Commission. 6705 Rockledge Drive, Suite 700, Rockville, MD 20892. (310) 402-4242. <http://www.bioethics.gov>.
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Ken R. Wells