Medical Ethics

Medical ethics probably began when Hippocrates, in his famous oath, defined the duties of physicians. The relationship between physician and patient was paternalistic, in which an informed physician made decisions in the interest of an uninformed patient. The oath sworn by all physicians remained without significant change for centuries, although it has been updated in recent decades.

The Nuremberg trials after World War II brought medical ethics into the spotlight. How was it possible that expert physicians like Josef Mengele could commit such horrific acts in the concentration camps of Nazi Germany? What should be done with the data gathered from his terrible experiments on patients? Should they be used for the benefit of humanity? Or should they be burned as a sign of respect for the dead and a desire to keep medicine pure?

The Holocaust had a profound impact on the development of medical ethics. The Nazi doctors' argument was that the suffering of one group of humans was justified for the benefit of another. In response to this, ethical systems emphasizing the patient's rights gained attention in medical ethics: namely, the American ethical doctrine of natural rights and Immanuel Kant's duty ethics. It was in reaction to this ethical regression that medical advances and their new technologies were judged by public opinion and courts of law. Hence, physicians, when faced with controversial decisions and deciding whose rights to prioritize over whose, find themselves attending to the rights of the patient.

One of the first hospitals to have a dialysis machine was the Swedish Hospital in Seattle, USA, where deciding who should be given access to this service and thus have their lives saved became such a major problem that in 1962 they formed a special ethics committee. Since then, ethics committees have become common worldwide and a permanent fixture of hospitals.

The Scope of the Subject and the Search for Theory

Several issues related to the physician-patient relationship dominate modern medical ethics: they include the duty to treat, confidentiality, and honesty. Other issues that have been raised include: medical experiments on humans with or without their knowledge, addressing public health emergencies, and the issue of profit. Technological advances have created a new category of problems. These problems have led to questions regarding the decision-making capacity of patients who are mentally incompetent (in psychiatry), or children (in pediatrics), or individuals not yet born (in genetic medicine).

These numerous issues are examined from several dimensions, one of which is the philosophical dimension: and decisions are judged based on rights-based ethics (Kantian), utilitarian ethics, and virtue ethics (Aristotelian).

Consider the example of abortion. The rights-based approach determines the rights of the mother and the unborn child and then attempts to determine whose right should prevail. The utilitarian approach attempts to compare the happiness of the mother against the happiness of the unborn child. The virtue ethics approach examines how a woman understands herself and how she wants to live her life; it then examines how the decision she makes will affect her life.

Other approaches also exist: feminism is becoming increasingly influential through its critique of the masculine nature of the physician's decision-making role. The school of thought founded on Carol Gilligan's approach promotes respect for differences and advises us to pay attention to how individuals view themselves in their relationships with others. Each case is judged based on the different merits observed by the patient. Like the Aristotelian approach, this approach does not address the question of how physicians should act, but rather the question of how patients should live.

A look at the medical ethics courses taught to doctors in England, Australia, and the United States shows that the only approach employed is the rights-based ethics approach. This approach, considering individuals as ends in themselves and not as means, and respecting individual autonomy, has been utilized by some modern ethical theorists such as Beauchamp, Childress, and Engelhardt.

The famous modern ethical theory proposed by Beauchamp and Childress (1) suggests four principles based on which issues should be examined: beneficence, non-maleficence, respect for autonomy, and finally, justice. These principles are founded upon a combination of a generally duty-based ethics with a kind of intuitive grasp of how medicine should be practiced. This approach has been very influential and much debated. Cases where two or more principles conflict are somewhat problematic, as is the very selection of the principles! Their definition of justice is also controversial.

One should not conclude that Kant is the most important figure in this field. While in the English-speaking world, medical ethics has been predominantly duty-based, some specialized fields have been significantly influenced by other approaches: organ transplantation has been influenced by utilitarianism, and the care of terminally ill patients by Aristotelian virtue ethics.

The search for general theories has been heavily criticized by Jonathan Glover in his famous book, Causing Death and Saving Lives, published in 1977. He examined the inadequacies of Kantian reliance on rights – where there is much debate about what rights actually exist and how to adjudicate when rights conflict. He also criticizes the utilitarian approach, which makes such judgments despite ignorance of what the resulting happiness from those judgments will be, judgments that are at best guesses based on experience or theoretical knowledge. He also critiques the virtue-based approach, where the judgment about which virtues to include on the list of virtues seems as arbitrary as the items of right on the duty-based list. Glover's argument is that the role of medical ethics is, in fact, to examine the historical principles upon which decisions have been made in complex cases and to attempt to find a coherent approach to decision-making in general.

Doctor-Patient Relationships

Many questions about the patient-doctor relationship are ancient ones, such as the issue of confidentiality. What should a doctor do upon discovering that their minor patient has been sexually abused by their parents, or that a promiscuous individual is cheerfully spreading sexually transmitted diseases? Doctors often possess confidential information that leaves them caught between their duty to the patient and their duties as a law-abiding citizen.

A major change has been that while doctors and patients were once content with the doctor making all the decisions, this method has now been replaced in the Western world by the paradigm of informed consent. Often, the patient has some degree of knowledge, wants more information, and demands a role in the decision-making process. This major shift has led to concerns being raised. For example, what do we do with those who cannot consent or whose decisions are perhaps arbitrary, such as children and individuals with mental disabilities? Attitudes towards medical experiments have also changed, especially research conducted on animals.

The shift from paternalism to informed consent has paved the way for another model of medical ethics, proposed by Tristram Engelhardt in the United States. (2) His argument is that in a fragmented and morally disjointed world, there are four methods for resolving ethical disputes. Three of these four are no longer effective. These four are: persuasion/conversion, valid rational arguments, force, and agreement—only agreement works in today's world. This idea resembles the concept of informed consent in medicine. Engelhardt's model permits certain interactions that Beauchamp and Childress oppose—such as allowing cases in which individuals must pay for their own medical treatment! A considerable number of books and articles have been written criticizing Engelhardt or extending his principles to specific issues in medical ethics.

Birth and Death

The rights-based approach in medical ethics is particularly compelling when examining issues related to contraception, fertility, and euthanasia. Two competing approaches dominate this debate; both argue strongly on the basis of human rights, yet they are rooted in differing views of human nature. The conservative view (adopted by many religious people) holds that human life is sacred and must not be ended: consequently, abortion is unacceptable, just as the activities of Dr. Jack Kevorkian—known as Dr. Death—and his colleagues, who performed euthanasia, incurred the wrath of this group. The other, more liberal view is founded on metaphysical arguments concerning the nature of value. Only living beings can hold values, and the value of a human life depends on how each person values their own life. There is no objective standard for determining such value, but it is evident that conscious individuals can make decisions about their own lives. In cases where a person lies in a persistent vegetative state in a hospital bed, the hypothetical decisions that person would likely have made before this incapacity are examined.

Arguments not based on human rights carry very little weight: hence, the utilitarian arguments of the Australian philosopher Peter Singer have had minimal impact, except to compel others to condemn the utilitarian approach. Singer's argument regarding fetuses with physical disabilities is that the happiness these children would attain over the course of their lives is far less than the loss of happiness experienced by their parents or those who must care for them. Such views have led to Singer's lectures being disrupted in Germany.

Genetic Control

With the continued success of the Human Genome Project, scientists have gained the ability to investigate many hereditary diseases, such as Tay-Sachs disease, and predispositions to various cancers and diabetes. Preimplantation genetic diagnosis (PGD) may prevent baldness, moles, or birthmarks and make all humans six feet taller.

The ability to perform such extraordinary feats leads to questions about their appropriateness. Making decisions for an individual you are counseling is one thing; making decisions for an unborn child with serious physical problems is another. Making decisions about minor matters such as height and baldness for people who will grow up in a society over several generations and whose values are still unknown is extraordinarily disingenuous, and such a prospect has prompted a wave of academic articles and books on the subject. The questions in this arena are profound and complex: Can an individual own the rights to the human genetic structure? Can individuals' DNA maps be published without their knowledge or permission? Can humans be cloned, and should clones be treated as human beings? Can brainless clones be produced as spare parts to be used when needed? All sorts of horrifying and controversial questions present themselves! Recently in Britain, debates have intensified with the decision to allow the cloning of human tissue. Medical ethics is one of the few areas in which philosophers have a direct influence on government policies. Ethicists such as John Polkinghorne, Baroness Mary Warnock, and Onora O'Neill play a prominent role in various committees and advisory sessions.

Medical ethics has grown rapidly with the great strides made in medical capabilities in the second half of this century. The wide range of choices that are now made routinely and their potentially horrific consequences have had major implications for physicians themselves. The ever-present reality of legal courts and the costly consequences of litigation (and high insurance premiums) have made even the most unscrupulous doctors realize the importance of arriving at the right decisions. The ability to broaden the scope of blame and include others in the process—such as medical ethics—has been a natural consequence of the modern era, during which the authority of many professions has been challenged. Sartre and the existentialists have also had their influence: doctors are no longer expected to make the correct decision; rather, the hope is that after examining all necessary factors and making a choice, doctors will arrive at a kind of right decision to the best of their ability.

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1. Principles of Bio-Medical Ethics, 1979
2. The Foundations of Bioethics, 1996

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Medical Ethics

Mark Daniels

Translation: Zohair Bagheri Noaparast

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