Medical ethics

Medical ethics is primarily a field of applied ethics, the study of moral values and judgments as they apply to medicine. 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 bioethics appears to have 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.

History
Historically, Western medical ethics may be traced to guidelines on the duty of physicians in antiquity, such as the Hippocratic Oath, and early rabbinic and Christian teachings. In the medieval and early modern period, the field is indebted to Islamic 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 Maimonides, Roman Catholic scholastic thinkers such as Thomas Aquinas, and the case-oriented analysis (casuistry) of Catholic moral theology.

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 Manchester wrote about "medical jurisprudence" and reportedly coined the phrase "medical ethics." In 1847, the American Medical Association adopted its first code of ethics, with this being based in large part upon Percival's work. 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 bioethics.

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.)
 * 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 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 dilemma 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 modern guidance in the form of its 'Good Medical Practice' statement.

Informed consent
Informed 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 legal requirements for decision-making capacity. Patients can elect to make their own medical decisions, or can delegate decision-making authority to another party. In some cases, the patient may be incapacitated, in which case U.S. state law designates a process for obtaining informed consent. In some American states, family members have differing levels of precedence over one another in making medical decisions for the patient, while other states recognize all family members equally in making medical decisions.

The value of informed consent is closely related to the values of autonomy and truth telling. American culture places a high value on these principles, finding justification in the U.S. Constitution and Declaration of Independence.

Confidentiality
Confidentiality 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. 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 abortion

Beneficence
The concept of doing good to humanity in general.

Autonomy
The 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 euthanasia, 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 morphine can ease the pain and suffering of the patient, while simultaneously hastening the demise of the patient through suppression of the respiratory drive.

Importance of communication
Many 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 committees
Many times, simple communication is not enough to resolve a conflict, and a hospital ethics committee of ad 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 comprised of health care professionals, philosophers, lay people, and still clergy.

The assignment of philosophers or clergy will reflect the importance attached by the society to the basic values involved. An example from Sweden with Torbjörn Tännsjö on a couple of such committees indicates secular trends gaining influence.

Cultural concerns
Culture 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 interest
Physicians 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".

Self-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.

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 fiduciary 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 health 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 Baby 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.

Reproductive medicine

 * Abortion/Abortion debate
 * Circumcision/Bioethics of neonatal circumcision
 * Human cloning
 * Gene splicing
 * Human genetic engineering
 * Eugenics

Medical research

 * Animal research
 * CIOMS Guidelines
 * Common rules. Adopted by 17 United States departments and agencies (1991).
 * Nuremberg Code
 * Declaration of Geneva
 * Declaration of Helsinki
 * Declaration of Tokyo
 * Good clinical practice
 * Health Insurance Portability and Accountability Act
 * Patients' Bill of Rights
 * Universal Declaration of Human Rights
 * Institutional Review Board
 * First-in-man study

Famous cases in medical ethics
Many famous cases in medical ethics illustrate and helped define important issues.
 * Willowbrook Study
 * Tuskegee Study
 * Terry Schiavo
 * Jack Kevorkian
 * Nancy Cruzan
 * Karen Ann Quinlan
 * Baby K
 * HeLa
 * TGN1412

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

Sources and References
Beauchamp, Tom L., and Childress, James F. 2001. Principles of Biomedical Ethics. New York: Oxford University Press.

Bioethics introduction

Brody, Baruch A. 1988. Life and Death Decision Making. New York: Oxford University Press.

Curran, Charles E. "The Catholic Moral Tradition in Bioethics" in Walter and Klein (below).

Fletcher, Joseph F. 1954. Morals and Medicine: The Moral Problems of: The Patient's Right to Know the Truth, Contraception, Artificial Insemination, Sterilization, Euthanasia. Boston: Beacon.

The Hastings Center's Bibliography of Ethics, Biomedicine, and Professional Responsibility.

Kelly, David. The Emergence of Roman Catholic Medical Ethics in North America. New York: The Edwin Mellen Press, 1979. See especially chapter 1, "Historical background to the discipline."

Sherwin, Susan. 1992. No Longer Patient: Feminist Ethics and Health Care. Philadelphia: Temple University Press.

Veatch, Robert M. 1988. A Theory of Medical Ethics. New York: Basic Books.

Walter, Jennifer and Eran P. Klein eds. The Story of Bioethics: From seminal works to contemporary explorations Georgetown University Press, 2003