Medical ethics

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Medical ethics, also known as health care ethics, or as biomedical ethics, is a field of applied ethics (see the article metaethics)—ethics applied to the fields of medicine and health care. Nursing ethics is sometimes considered to be a separate field or is sometimes held to be a sub-field of medical ethics. In any case, medical ethics and nursing ethics are closely related, and nursing ethics will be treated here as a sub-field of medical ethics.

Contents

Concern about medical ethics goes back to antiquity, especially with the work of Hippocrates. Today the field has become very large and broad, with many books, textbooks, academic journals, and other publications. There are now many seminars and conferences on the topic, and medical ethics boards and teams exist in many hospitals and other sites of medical practice as well as in legislative and legal chambers and proceedings. Today, in addition to doctors and nurses and other health care professionals, many different people are concerned with and are frequently called upon to offer judgments and opinions on the topic or on concerns and cases that arise within the field of medical or health care ethics. Those people include philosophers, ethicists, hospital and other healthcare administrators, health insurance officials, theologians, ecologists, economists, family planners, legislators and politicians, lawyers and jurists, and others.

Why medical ethics matters

Centrally, medicine and health care deal with human health, life, and death, and medical ethics deals with ethical norms for the practice of medicine and health care—or how it ought to be done—so the concerns of medical ethics are among the most important and consequential in human life.

Part of the importance of medical ethics comes from the fact that members of the medical and health care professions are granted powers and privileges that are not granted to non-members. Surgeons and doctors have the right and duty to cut open the human body if they are convinced that by doing so they can improve or aid the health of the person being cut. Medical professionals get to determine or decide, at least sometimes, who is to live and who will die. They can prescribe powerful drugs and chemicals that would or could be poisonous or otherwise harmful if improperly administered. They make decisions about the use and allocation of large amounts of money and scarce resources. They decide how patient care is to be delivered, which patient should get which resources, how much and what patients should and will be told about their situation, what kind of doctor-patient interaction will occur, and whether the information given to them by patients will be kept confidential, and, if not, how and to whom it will be shared.

Those questions and issues affect every human being at some point in each person's life.

Some reasons medical ethics problems arise

Problems of health-care ethics arise for numerous reasons. One is the power of physicians over human life and death, and the potential for physicians and other health care workers to misuse this power or to be careless with it.

One of the most important and consequential of reasons for the rise of problems of ethics in health care comes from the development and growth of health-care technology. Doctors have many means nowadays to keep people technically alive by hooking them up to various machines. But these means are usually both expensive and invasive. Who should decide what to do and when to do it, when to let a brain dead patient die, is a potential gray area. Suppose there is a disagreement among the family members of a comatose patient in such circumstances: Whose opinion or desires or interest should take precedence? Suppose the medical professionals have one opinion but the family members have a different one: Whose opinion should be followed then?

For another example, doctors now have the means to do organ transplants, such as kidney, lung, and heart transplants. But there are almost always more people in need of such organs than there are organs available for transplanting. So which of the patients who need them should get the available organs, and what criteria should be used to make the decision?

Another important source of health-care ethics problems nowadays comes from the high costs of health care and the resulting question of who should pay for it and how these costs are to be paid and allocated. Is health-care a positive human right, so that every person who needs it or who would benefit from it should have equal access to the most expensive forms of health care regardless of ability to pay? If so, then should taxation, at whatever rate would be necessary, be raised in order to pay for this? Is there a social requirement that the public at large should foot the bill for universal health care? Should a hospital be required to treat indigent patients if this will mean that the hospital will incur millions of dollars of unrecoverable costs? Suppose the hospital, because of its having so many such cases, is thus faced with bankruptcy? In that case, who should pay those costs? Is it ethically permissible for a hospital to overcharge its paying patients—charging as much as $100 for a single aspirin, for example, as they often do—so as to recoup costs incurred by non-paying patients? What about so-called crack babies—babies born deformed and addicted to crack because their mothers were on crack cocaine during the pregnancy? These babies can cost as much as several thousand dollars or even more per day in hospital costs, going on for a year or more, with little prospect for the child ever having a healthy life. Is this a reasonable expenditure? What would be the alternative? All of these are hard questions that medical ethicists carefully consider, from all vantage points.

Principles of medical ethics

Ethicists and philosophers have suggested many methods to help evaluate the ethics of a situation. These methods attempt to provide principles that health care professionals—doctors, nurses, administrators of medical institutions—should consider while making decisions.

Some philosophers, such as Thomas Mappes and David DeGrazia, have found William David Ross's account of prima facie duties to be helpful in solving problems of medical ethics. Others have used one or more of the conventional ethical theories: Utilitarianism (consequentialism or teleological theories) or Kantian ethics (non-consequentialism). Some people use divine command ethics—ethics based on religious views about the supposed command or will of God—as their basis for deciding problems of health care ethics. Some people and ethical systems attempt to decide these issues based on what they understand to be natural law. Some people are libertarian in their approach, wanting as much as possible to allow the individual patient to decide for himself or herself. Still others turn to feminist ethics or what is known as the ethics of care. Casuistry, or case-based reasoning—something that was widely used and advocated three centuries ago and before, but has since then has gone into disuse—has also gotten a great deal of attention recently, based on Albert Jonsen and Stephen Toulmin's The Abuse of Casuistry.

Others, such as Mappes and DeGrazia, have proposed a number of principles that they suggest will help solve problems of biomedical ethics. Six of the principles commonly included 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.)
  • Justice—concerns the distribution of scarce health resources, and the decision of who gets what treatment.
  • Dignity—the patient (and the person treating the patient) have the right to dignity.
  • Truthfulness and honesty—the patient should not be lied to, and deserves to know the whole truth about their illness and treatment (though certain exceptions are made for the proper use of placebos).

Principles such as these do not by themselves give answers as to how to handle a particular situation, but can serve to guide doctors on what principles ought to apply to actual circumstances. The principles sometimes contradict each other leading, to ethical dilemmas. For example, the principles of autonomy and beneficence clash when patients refuse life-saving treatments.

To reconcile conflicting principles, Bernard Gert, a philosopher who specializes in medical ethics, propounds a theory that would require doctors to advocate their action publicly if they were to violate any basic moral principles (e.g., break a promise in order to save a life). Other philosophers, such as R. M. Hare, would require the formulation of a universal prescription in conformance with logic, such that all rational parties, including the patient (assuming he is rational), would subscribe to the same action in all circumstances that share the same essential properties.

In the United Kingdom, the General Medical Council provides clear modern guidance in the form of its Good Medical Practice[1] statement. In the United States, the American Medical Association has devoted a great deal of effort to publish guidelines and principles for medical ethics for physicians.[2]

Areas of concern for biomedical ethics

As suggested above, there is a very large number of problems and questions encompassed under the heading of medical or health-care ethics. Following Mappes and DeGrazia, one way of attempting to deal with as many of these as possible is to group them under headings. That tactic will be used here. Particular questions will be listed under headings that group those questions or issues, but it should not be concluded that these are all the issues that can or do arise, or that these headings are fixed or exhaustive. This is a growing field that is in much flux. Any new medical technology almost inevitably raises new ethical problems. Thus, only a handful of dilemmas are addressed here:

Some ethical issues in the physician-patient relationship

What are the obligations and virtues of a physician? What is the best physician-patient relationship: Paternalistic, informative, interpretive, or deliberative? How much autonomy should patients be given? Must patients always be told the truth, even if the health-care professional is convinced that this will be injurious to the patient’s situation? What is informed consent, what is its role, and can it be given in difficult cases? Generally informed consent is held to require satisfaction of three conditions: Complete information must be given to the one who is to give consent; the consent must not be coerced, and the consenter must be competent to give consent. Is it permissible for one person—a spouse or family member or guardian—to give consent for another adult? Can a person from a poor and uneducated population really fulfill the conditions for informed consent?

What about situations when there in disagreement within the medical profession about the efficacy or advisability of certain therapies—whose opinion or choice should prevail in such cases? What about multicultural societies and differing cultural and ethical views about health care issues—whose view should take precedence in such situations? What about conflicts of interest within the medical profession? Should doctors be required to provide therapies—such as abortion—if they are personally ethically opposed to them? Should there be a patients' bill of rights to spell out or specify just what rights a patient should receive or expect, especially in difficult or controversial circumstances?

The problem of confidentiality

Most people think that their medical records should be confidential. Many therapy and counseling sessions require professional-patient confidentiality. But what if the patient reveals to the doctor that the patient is doing something that poses serious harm to a third person—can the professional break confidentiality is such situations? If so, what procedure should be followed? Also, nowadays most people’s health care, at lest in the United States, is paid for through medical insurance plans that are at least partly financed by employers. Does this give employers and medical insurance companies a right to examine or know the contents of the medical records of the people for who they are paying?

Special ethical problems for nurses

Nurses generally serve under and at the instruction of doctors. Suppose a nurse is convinced that the doctor is making a serious medical or other error—what ethical right or duty does the nurse have in such a situation? Suppose the patient asks the nurse for information about the patient’s case that the doctor has told the nurse not to give to the patient—what should the nurse do in such a situation? Should nurses attempt to keep the cost of health care down for the hospitals for which they work?

Some ethical issues in human and animal research

Today there are ethical codes that cover human and animal research. How good are these codes? Is it ethically permissible to do human medical research in places where people are poor and not well educated and thus perhaps unable to give genuine informed consent, such as developing nations? Is proxy consent sufficient for patients incapable of giving informed consent, and who should give that proxy consent? What about the use of human tissue in medicine, including blood transfusions and growth hormone treatments—are these ethically permissible? What if the patient has ethical objections to such therapy but the medical professionals do not and think this therapy is necessary—whose opinion should be followed in such cases? Suppose the case has to do with a young child, but the parents have ethical objections to this therapy—what then? What about research on animals—do animals have ethical rights that should be respected, and what is responsible or ethically permissible use of animals in such research, and what is irresponsible or impermissible?

Some ethical issues in death and dying?

What is the proper definition of death? Should competent adults be able (free) to refuse life-sustaining treatment? Do advance directives and living wills solve the problem of what is to be done with now-incompetent patients? Should DNR (do not resuscitate) orders be followed? What is medical futility and when is it reached? If the medical professionals are convinced that medical futility is reached yet the next of kin or guardian of a patient demands further medical interventions, then what? What are the proper standards of treatment for impaired infants?

Ethical issues in suicide, physician-assisted suicide, and active euthanasia

Is suicide ever ethically right or justified? If it is, is physician-assisted suicide ethically right or justified. What about active euthanasia (i.e. actively killing the patient by, for example, administering a lethal drug)? If active euthanasia is not ethically justified, might passive euthanasia (such as withdrawing hydration and nutrition, but not actively administering anything to bring about death of the patient) be ethically permitted? What should social and governmental policy be with regard to physician-assisted suicide, active euthanasia, and passive euthanasia? If physician assisted suicide and euthanasia are permitted, will this lead to a slippery slope in which doctors will attempt to persuade or even coerce some patients into ending their lives?

Ethical issues in abortion and embryonic stem cell research

Is abortion ever ethically permissible?—what is the ethical status or acceptability of the yes and no answers to that question. Can there be a moderate view on the abortion question? Is a fetus a person with ethical rights? Who should get to decide the abortion question—the woman? The woman in consultation with her partner? With her family? The government? Does the male involved have any ethical rights with regard to this decision? What should governmental and social policy on abortion be? Is research conducted on embryonic stem cells ethically permissible? Why or why not? Does the stem cell constitute a person? Which is the proper or best or desireable ethical case concerning cloning—for it, against it, or some moderate position?

Ethical issues in genetics and human reproduction

Is it ethically permissible to test fetuses for genetic defects and to about those that are deemed by someone—whether medical professionals, legislators, parents, or others—to be defective or undesirable? Is it ethically permissible to determine the sex of the fetus pre-natally so that a fetus of the undesired sex (usually girls) can be aborted? Is it ethically permissible to text for possible genetic markers for disease and then to use those for purposes of determining eligibility for health insurance or employment? What is the ethical status of in vitro fertilization? Use of fertility drugs that result in multiple pregnancies? Suppose too many multiple pregnancies occur in a given case—is it ethically permissible to kill some of those fetuses so that the remaining ones can grow more healthy? Is it ethically permissible to do gene therapy? What about gene manipulations to create "designer babies" in order to please prospective parents? Should patients decide these issues for themselves, or should there be social or governmental standards and laws about them?

Ethical issues in health care policy

What ethical obligation or responsibility does society and government have for health care? Should all people have equal access to health care regardless of their ability to pay or their social status? Can health-care rationing be ethically justified? If not, what about those situations in which failure to ration bankrupts health care systems or hospitals? What are fair procedures for managed care systems? Is it ethically permissible for different states and countries to have substantially different health care systems? Who should get to decide on public policy issues regarding health care? How should priorities in health care be set and managed, assuming that priorities will almost always be necessary?

Critiques of conventional medicine

Many people are critical of conventional medicine or the prevailing health care system. There are numerous reasons for such criticisms and concerns. Here are some of them:

  • Physician's Committee for promoting responsible medicine[3] [4]
  • Acceptability of toxicity in conventional medication (e.g. chemotherapy)
  • Iatrogenic illness caused by medicine itself
  • Institutional Damage caused by long term stay in hospitals, which is not an ideal substitute for family care and education.
  • Invasiveness and inherent dangers of surgery
  • Medical error
  • Pervasiveness of medical advertising and material rewards for prescribing drugs which doctors are "bombarded" with—possibly placing emphasis on profits rather than patient wellbeing

Critiques of alternative medicine

In addition to the criticisms of conventional medicine, there are many people who are critical of non-conventional (or alternative) medical procedures, ideas, and systems. Some of the reasons for those criticisms are:

  • Issues of compatibility between varieties of alternative medicine and the scientific method
  • The question whether there is proper or good regulation of pre-scientific or extra-scientific medicine
  • The possibility that patients or their family members are being deceived or given false hopes by advocates of unconventional treatments and procedures

Notes

  1. Good Medical Practice (2006), General Medical Council. Retrieved May 21, 2007.
  2. Medical ethics, American Medical Association. Retrieved May 23, 2007.
  3. Physician's Committee for promoting responsible medicine, Physicians Committee for Responsible Medicine. Retrieved May 8, 2008.
  4. Physicians Committee for Responsible Medicine, Physicians Committee for Responsible Medicine. Retrieved May 8, 2008.

Bibliography

  • Ashley, Benedict M., Jean deBlois, and Kevin D. O'Rourke. Health Care Ethics: A Catholic Theological Analysis, 5th Edition. Washington, DC: Georgetown University Press, 2006. ISBN 1589011163
  • Beauchamp, Tom, and James Childress. Principles of Biomedical Ethics, 4th Edition. New York: Oxford University Press, 1994. ISBN 0195085361
  • Carrick, Paul. Medical Ethics in the Ancient World. Washington, DC: Georgetown University Press, 2001. ISBN 0878408495
  • Jonsen, Albert R. and Stephen Toulmin. The Abuse of Casuistry: A History of Moral Reasoning, Berkeley, CA: University of California Press, 1988. ISBN 0520060636
  • Pence, Gregory E., Classic Cases in Medical Ethics, 3rd Edition. New York: McGraw-Hill Higher Education, 2000. ISBN 0073039861
  • Mappes, Thomas A., and David DeGrazia (eds.). Biomedical Ethics, 6th Edition. New York: McGraw-Hill Higher Education, 2006. ISBN 0072976446

External links

All links retrieved December 4, 2013.

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