Medical ethics
Medical ethics is primarily a field of
applied ethics, the study of
oral
values and judgments as they apply to
edicine.
As a scholarly discipline, medical ethics encompasses its practical application
in clinical settings as well as work on its history, philosophy, theology, and
sociology.
Medical ethics tends to be understood narrowly as an applied professional
ethics, whereas
ioethics
appears to have worked more expansive concerns, touching upon the
philosophy of science and the critique of
biotechnology. Still, the two fields often overlap and the distinction is
more a matter of style than professional consensus.
Medical ethics shares many principles with other branches of
healthcare ethics, such as
nursing ethics.
HistoryHistorically,
Western medical ethics may be traced to guidelines on the
uty of physicians
in antiquity, such as the
Hippocratic Oath, and early
abbinic
and hristian
teachings. In the medieval and early modern period, the field is indebted to
Muslim physicians such as Ishaq bin Ali Rahawi (who wrote the Conduct of
a Physician, the first book dedicated to medical ethics) and
al-Razi (known as Rhazes in the West),
Jewish thinkers such as
aimonides,
Roman Catholic
scholastic thinkers such as
Thomas Aquinas, and the case-oriented analysis (asuistry)
of Catholic
moral theology. These intellectual traditions continue in Catholic,
Islamic and
Jewish medical ethics.
By the 18th and 19th centuries, medical ethics emerged as a more
self-conscious discourse. For instance, authors such as the British Doctor
Thomas Percival (1740-1804) of
anchester
wrote about "medical jurisprudence" and reportedly coined the phrase "medical
ethics." Percival's guidelines related to physician consultations have been
criticized as being excessively protective of the home physician's reputation.
Jeffrey Berlant is one such critic who considers Percival's codes of physician
consultations as being an early example of the anti competitive, "guild", like
nature of the physician community.
In 1847, the
American Medical Association adopted its first
ode of
ethics, with this being based in large part upon Percival's work
[2]. While the secularized field borrowed largely from Catholic medical
ethics, in the 20th century a distinctively
liberal Protestant approach was articulated by thinkers such as
Joseph Fletcher. In the 1960's and 1970's, building upon
liberal theory and
procedural justice, much of the discourse of medical ethics went through a
dramatic shift and largely reconfigured itself into
ioethics.
Values in medical ethics
Six of the values that commonly apply to medical ethics discussions are:
-
Beneficence - a practitioner should act in the best interest of the
patient. (Salus aegroti suprema lex.)
-
Non-maleficence - "first, do no harm" (primum non nocere).
-
Autonomy - the patient has the right to refuse or choose their
treatment. (Voluntas aegroti suprema lex.)
- ustice
- concerns the distribution of scarce health resources, and the decision of
who gets what treatment (fairness and equality).
- ignity
- the patient (and the person treating the patient) have the right to
dignity.
- ruthfulness
and onesty
- the concept of
informed consent has increased in importance since the historical events
of the
Doctors' Trial of the Nuremberg trials and
Tuskegee Syphilis Study.
Values such as these do not give answers as to how to handle a particular
situation, but provide a useful framework for understanding conflicts.
When moral values are in conflict, the result may be an ethical
ilemma or
crisis. Writers about medical ethics have suggested many methods to help resolve
conflicts involving medical ethics. Sometimes, no good solution to a dilemma in
medical ethics exists, and occasionally, the values of the medical community
(i.e., the hospital and its staff) conflict with the values of the individual
patient, family, or larger non-medical community. Conflicts can also arise
between health care providers, or among family members. For example, the
principles of autonomy and beneficence clash when patients refuse life-saving
blood transfusion, and truth-telling was not emphasized to a large extent
before the HIV era.
In the United Kingdom,
General Medical Council provides clear overall modern guidance in the form
of its 'ood
Medical Practice' statement. Other organisations, such as the
Medical Protection Society and a number of university departments, are often
consulted by British doctors regarding issues relating to ethics.
How does one ensure that appropriate ethical values are being applied within
hospitals? Effective
hospital accreditation requires that ethical considerations are taken into
account, for example with respect to physician integrity, conflicts of interest,
research ethics and
organ transplantation ethics.
Informed consentInformed Consent in ethics usually refers to the idea that an
uninformed agent is at risk of mistakenly making a choice not reflective of his
or her values. It does not specifically mean the process of obtaining consent,
nor the specific legal requirements, which vary from place to place, for
decision-making capacity. Patients can elect to make their own medical
decisions, or can delegate decision-making authority to another party. If the
patient is incapacitated, laws around the world designate different processes
for obtaining informed consent, typically by having the
next-of-kin make decisions for the incapacitated patient.
The value of informed consent is closely related to the values of autonomy
and truth telling. The American legal system places a high value on these
principles, finding justification in the U.S. Constitution and Declaration of
Independence.
ConfidentialityConfidentiality is commonly applied to conversations between doctors
and patients. This concept is commonly known as patient-physician privilege.
Legal protections prevent physicians from revealing their discussions with
patients, even under oath in court. Confidentiality is mandated in
America by
HIPAA laws, specifically the Privacy Rule, and various state laws, some more
rigorous than HIPAA. Confidentiality is challenged in cases such as the
diagnosis of a sexually transmitted disease in a patient who refuses to reveal
the diagnosis to a spouse, or in the termination of a pregnancy in an underage
patient, without the knowledge of the patient's parents. Many states in the U.S.
have laws governing parental notification in underage abortion3]
BeneficenceThe concept of doing good to humanity in general.
This is the principle of taking actions that benefit your patient, and that
is in their best interest. It is not an absolute principle in that it only
applies to your patients, unlike the principle on non-maleficence.
AutonomyThe principle of Autonomy recognizes the rights of individuals to self
determination. This is rooted in society�s respect for individuals� ability to
make informed decisions about personal matters. Autonomy has become more
important as social values have shifted to define medical quality in terms of
outcomes that are important to the patient rather than medical professionals.
The increasing importance of Autonomy can be seen as a social reaction to a
�paternalistic� tradition within healthcare. Respect for autonomy is the basis
for informed consent and advance directives. Autonomy can often come into
conflict with Beneficence when patients disagree with recommendations that
health care professionals believe are in the patient�s best interest.
Individuals� capacity for informed decision making may come into question during
resolution of conflicts between Autonomy and Beneficence. The role of surrogate
medical decision makers is an extension of the principle of Autonomy.
Non-Maleficence
The concept of non-maleficence is embodied by the phrase, "first, do no
harm," or the Latin,
primum non nocere. Physicians are obligated under medical ethics to not
prescribe medications they know to be harmful. American physicians interpret
this value to exclude the practice of
uthanasia,
though not all concur. Probably the most extreme example in recent history of
the violation of the non-maleficence dictum was Dr.
Jack Kevorkian, who was convicted of second-degree homicide in Michigan in
1998 after demonstrating active euthanasia on the TV news show, 60 Minutes.
Non-maleficence is a legally definable concept. Violation of non-maleficence
is the subject of
medical malpractice litigation.
Double effect
Some interventions undertaken by physicians can create a positive outcome
while also potentially doing harm. The combination of these two circumstances is
known as the "double effect." The most applicable example of this phenomenon is
the use of morphine in the dying patient. Such use of
orphine
can ease the pain and suffering of the patient, while simultaneously hastening
the demise of the patient through suppression of the
respiratory drive.
Criticisms of orthodox medical ethicsIt has been argued that mainstream medical ethics is biased by the assumption
of a framework in which individuals are not simply free to contract with one
another to provide whatever medical treatment is demanded, subject to the
ability to pay. Because a high proportion of medical care is typically provided
via the welfare state, and because there are legal restrictions on what
treatment may be provided and by whom, an automatic divergence may exist between
the wishes of patients and the preferences of medical practitioners and other
parties. Tassano
has questioned the idea that Beneficence might in some cases have priority over
Autonomy. He argues that violations of Autonomy more often reflect the interests
of the state or of the supplier group than those of the patient.
Importance of communicationMany so-called "ethical conflicts" in medical ethics are traceable back to a
lack of communication. Communication breakdowns between patients and their
healthcare team, between family members, or between members of the medical
community, can all lead to disagreements and strong feelings. These breakdowns
should be remedied, and many apparently insurmountable "ethics" problems can be
solved with open lines of communication.
Ethics committeesMany times, simple communication is not enough to resolve a conflict, and a
hospital ethics committee of
d hoc
nature must convene to decide a complex matter. Permanent bodies, ethical boards
are established to a greater extent as ethical issues tend to increase. These
bodies are composed of health care professionals,
philosophers, lay people, and still
lergy.
The assignment of philosophers or clergy will reflect the importance attached
by the ociety
to the basic values involved. An example from
weden with
Torbj�rn T�nnsj� on a couple of such committees indicates
secular trends gaining influence.
Cultural concernsCulture differences can create difficult medical ethics problems. Some
cultures have spiritual or magical theories about the origins of disease, for
example, and reconciling these beliefs with the tenets of Western medicine can
be difficult.
Truth-telling
Some cultures do not place a great emphasis on informing the patient of the
diagnosis, especially when cancer is the diagnosis. Even American culture did
not emphasize truth-telling in a cancer case, up until the 1970s. In American
medicine, the principle of
informed consent takes precedence over other ethical values, and patients
are usually at least asked whether they want to know the diagnosis.
Conflicts of interestPhysicians should not allow a conflict of interest to influence medical
judgment. In some cases, conflicts are hard to avoid, and doctors have a
responsibility to avoid entering such situations. Unfortunately, research has
shown that conflicts of interests are very common among both academic physicians
and physicians in practice.
The
The Pew Charitable Trusts has
announced the
Prescription Project for "academic medical centers, professional medical
societies and public and private payers to end conflicts of interest resulting
from the $12 billion spent annually on pharmaceutical marketing".
Referral
For example, doctors who receive income from referring patients for medical
tests have been shown to refer more patients for medical tests
. This practice is proscribed by the American College of Physicians
Ethics Manual .
Fee splitting and the payments of commissions to attact referrals of
patients is considered unethical and unacceptable in most parts of the world. It
is tolerated, though, in some areas of US medical care.
Vendor relationships
Studies show that doctors can be influenced by drug company inducements,
including gifts and food.
Industry-sponsored Continuing Medical Education (CME) programs influence
prescribing patterns.
Many patients surveyed in one study agreed that physician gifts from drug
companies influence prescribing practices.
A growing movement among physicians is attempting to diminish the influence of
pharmaceutical industry marketing upon medical practice, as evidenced by
Stanford University's ban on drug company-sponsored lunches and gifts. Other
academic institutions that have banned pharmaceutical industry-sponsored gifts
and food include the University of Pennsylvania, and Yale University.
Treatment of family members
Many doctors treat their family members. Doctors who do so must be vigilant
not to create conflicts of interest or treat inappropriately..
Sexual relationships
Sexual relationships between doctors and patients can create ethical
conflicts, since sexual consent may conflict with the
iduciary
responsibility of the physician. Doctors who enter into sexual relationships
with patients face the threats of deregistration and prosecution. In the early
1990's it was estimated that 2-9% of doctors had violated this rule.
Futility
Advanced directives include
living wills and durable
powers of attorney for healthcare. (See also
Do Not Resuscitate and
cardiopulmonary resuscitation) In many cases, the "expressed wishes" of
the patient are documented in these directives, and this provides a framework to
guide family members and
ealth
care professionals in decisionmaking when the patient is incapacitated.
Undocumented expressed wishes can also help guide decisionmaking, in the absence
of advanced directives. "Substituted judgement" is the concept that a family
member can give consent for treatment if the patient is unable (or unwilling) to
give consent himself. The key question for the decisionmaking surrogate is not,
"What would you like to do," but instead, "What do you think the patient would
want in this situation." Courts have supported family's arbitrary definitions of
futility to include simple biological survival, as in the
aby K case. A
more in-depth discussion of futility is available at
futile medical care.
-
Baby Doe Law Establishes state protection for a disabled child's right
to life, ensuring that this right is protected even over the wishes of
parents or guardians in cases where they want to withhold treatment.
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