Medical Ethics Health Article

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.

Professional implications

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.