Medical ethics
Medical ethics, also known as health care ethics, and sometimes 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 and 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.
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, and other publications, academic journals, seminars and conferences on the topic, and medical ethics boards and teams in many hospitals and other sites of medical practice, as well as in legislative and legal chambers and proceedings Today, many different people are concerned with and frequently are called upon to offer judgments and opinions on the topic or on concerns and cases that arise within the field of medical or healthcare ethics. Those people include philosophers, ethicists, physicians, nurses, 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.
Some Reasons Medical Ethics Problems Arise
Problems of health-care ethics arise for numerous reasons. One of the most important and consequential of those reasons nowadays is the development and growth of health-care technology. We 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. Should the fact that we have the technical means to do something mean that we should, ethically speaking, do it? Who should decide what to do and when to do it in such cases? 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 in such cases?
For another example, we 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. 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. 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 ther ea 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 an aspirin, for example — 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 during the pregnancy? These can cost $10,000 or more per day in hospital costs, going on for a year or more, with little prospect for having a healthy life. Is this a reasonable expenditure? What would be the alternative?
Principles for Medical Ethics
Ethicists and philosophers have suggested many methods to help evaluate the ethics of a situation. These methods provide principles that health care professionals — doctors, nurses, administrators of medical institutions — should consider while making decisions.
Some philosophers, such as Mappes and DeGrazia, have found W.D. Ross's account of prima facie duties to be helpful in solving problems of medical ethics. (See the article William David Ross for an account of Ross's view.) Others have used one or more of the conventional ethical theories: utilitarianism (consequentialism or teleological theories) or Kantian ethics (non-consequentialism). 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 blood transfusion.
To reconcile conflicting principles, Bernard Gert, a philosopher who specializes in medical ethics, propounds a theory that would require us to advocate our action publicly if we 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 us to formulate 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, General Medical Council provides clear modern guidance in the form of its 'Good Medical Practice' statement.
Areas of Concern for Biomedical Ethics
As suggested above, there are 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. This is a growing field that is in much flux. Any new medical technology almost inevitably raises new ethical problems.
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. Can a person from a poor and uneducated population really fulfill those conditions? 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?
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 harm or will harm 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 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 and 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 which they work?
Death and dying
- Euthanasia
- Final directives and ethics of resuscitation and the withdrawal of life support (See also Do Not Resuscitate and cardiopulmonary resuscitation)
- Use of human tissue in medicine, including blood transfusion and growth hormone treatment.
Reproductive medicine
Medical research
- Animal research
- Belmont Report
- CIOMS Guidelines
- Declaration of Geneva
- Declaration of Helsinki
- Declaration of Tokyo
- Human experimentation
- Nuremberg Code
- Patients' Bill of Rights
- Stem cell research
- Universal Declaration of Human Rights
- Willowbrook Study
Distribution and utilization of research and care
- Accessibility of health care
- Basis of priority for organ transplantation
- Institutionalization of care access through HMOs and medical insurance companies
Critiques of conventional medicine
- Committee for promoting responsible medicine
- 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
- Issues of compatibility between varieties of alternative medicine and the scientific method
- Regulation of pre-scientific medicine
Bibliography
- Beauchamp, Tom, and Childress, James, Principles of Biomedical Ethics, 4th Edition, New York: Oxford University Press, 1994. ISBN 0195085361; ISBN 019508537X
- Carrick, Paul, Medical Ethics in the Ancient World, Washington, DC: Georgetown University Press, 2001. ISBN 0878408495
- Pence, Gregory E., Classic Cases in Medical Ethics, 3rd Edition, Boston & New York: McGraw-Hill Higher Education, 2000. ISBN 0073039861
- Mappes, Thomas A., and DeGrazia, David, Eds., Biomedical Ethics, 6th Edition, Boston & New York: McGraw-Hill Higher Education, 2006. ISBN 0072976446
External links
- BMJJournals.com - 'JME Online: An international peer review journal for health professionals and researchers in medical ethics', Journal of Medical Ethics
- The HastingsCenter.org - 'The Hastings Center: Leading Bioethics into the Future'
- UChicago.edu - MacLean Center for Clinical Medical Ethics, University of Chicago Department of Medicine
- Washington.edu - 'Ethics in Medicine: Bioethics Topics', University of Washington School of Medicine
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