Medical ethics

From the beginning of the history of medicine, healers have had to deal withquestions of ethics. However, the separate discipline of medical ethics has existed for less than 50 years, largely prompted by 20th-century advances in life-support technology. Today, the formulation of medical ethics has become amultidisciplinary endeavor, often involving teams that may include clergy, philosophers, scientists, and lawyers, as well as physicians and nurses.

The Hippocratic Oath, attributed to the ancient Greek physician Hippocrates,is one of the best-known statements of ethical practice. It required physicians to "abstain from whatever is deleterious and mischievous," seeking only the benefit of their patients. Doctors taking the oath swore: "I will give no deadly medicine to anyone if asked, nor suggest any such counsel; and in likemanner I will not give to a woman a pessary (a device worn in the vagina) toproduce abortion. With purity and with holiness I will pass my life and practice my art. I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work." Furthermore, the Hippocratic Oath prohibited sexual relations with patients, and established the principle of medical confidentiality: "Whatever, in connection with my professional practice or not in connection with it, I see or hear, in the life ofmen, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret."

Second only to the Hippocratic Oath in its influence on medical ethics has been the Prayer of Moses Maimonides. Maimonides (1135 to 1204 A.D.) was court physician to the sultan Saladin, a Muslim military leader. In his prayer, thephysician beseeches Almighty God to keep him from allowing thirst for profitor ambition for renown and admiration to interfere with his profession, and goes on to ask God to preserve the strength of his body so that he will ever be ready to help and support rich and poor, good and bad, and enemy as well asfriend.

Another landmark work was the Code of Ethics of the American Medical Association, created at the AMA's first meeting in 1847. At that gathering, 268 doctors from 22 U.S. states agreed to be bound by a uniform code of ethics, whichadded humanistic elements not present in the Hippocratic Oath. For example, the 5,298-word AMA document required physicians to treat their patients with "attention, steadiness, and humanity" and to be "vigilant for the welfare of the community." In cases when "pestilence prevails," doctors were expected to"face the danger and to continue their labors for the alleviation of suffering, even at the jeopardy of their own lives." The 1847 code required AMA members to respect patient confidentiality, avoid overcharging for their services,provide free services in cases of poverty, and to never abandon a patient ifa case was considered incurable. Since 1847, the AMA code has been revised extensively. The current version begins with seven basic principles that serveas an introduction to medical ethics:

  • "A physician shall be dedicatedto providing competent medical service with compassion and respect for humandignity."
  • "A physician shall deal honestly with patients and colleagues, and strive to expose those physicians deficient in character or competence, or who engage in fraud or deception."
  • "A physician shall respect the law and recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient."
  • "A physician shall respect the rights of patients, of colleagues, and of other healthprofessionals, and shall safeguard patient confidences within the constraints of the law."
  • "A physician shall continue to study, apply, and advance scientific knowledge, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talent of other health professionals when indicated."
  • "A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical services."
  • "A physician shall recognize a responsibility to participate in activities contributing to an improved community."

In addition to these fundamental principles, the AMA code also includes a statement about the doctor-patient relationship, and dozens of opinions releasedby the AMA's Council on Ethical and Judicial Affairs. These opinions, released at an average rate of about eight per year, cover a wide range of ethicalissues. Medical ethics is far from being a static field.

In 1948, the Second World Medical Assembly adopted a modern equivalent of theHippocratic Oath. Known as the Declaration of Geneva, the declaration was amended in 1968 and again in 1983. Among its provisions, the declaration does not permit "considerations of religion, nationality, race, party politics or social standing to intervene between (the physician's) duty and (his/her) patient," and requires that the "health of the patient" be the physician's "firstconsideration."

Developments in life-support technology during the 1960s, and more recent advances in reproductive technology and genetics, have prompted intense interestin medical ethics. Many current issues in medical ethics revolve around definitions of human life or the value placed upon it. Such issues include

  • abortion
  • death
  • eugenics, euthanasia and physician-assistedsuicide
  • human experimentation
  • in-vitro fertilization
  • organ transplantation

Many of the ethical dilemmas that arise as issues surrounding abortion focuson the rights of the mother over her own body, the point at which human lifeis to be distinguished from non-human life, and the reasons, if any, for protecting human life in the prenatal period. Ethical questions about death and dying have addressed brain death, the right to die, the use and withdrawal oflife support systems, and the prolongation of the life of brain dead mothersduring pregnancy. Ethical considerations of human experimentation have focussed on the uniqueness of human experimentation, the relationship of the individual to society, health as a public good, informed consent and nondisclosure,special privileges of the sick, the definition of death, the design of experiments, the distinctions between research and practice, therapeutic versus nontherapeutic research, risk, and intentional deception. Concerns expressed byethicists about organ transplantation have addressed, besides the definitionof death (and the use of legally dead yet breathing corpses for the purposesof experimentation, transplantation, training of physicians, and the production of needed hormones and antibodies), such issues as organ procurement, theright to health care, and concerns of fairness relating to transplantation.

Most ethical decisions in medicine are based on theories of ethics. These theories provide a common means to approach problems, and lend consistency to the decision making process. In the theory of ethics, consequentalism addressesthe question "What shall I do?" in terms of the consequences of an act, withwhat is ethical being defined as that which brings about the greatest good for the greatest number of people. Deontological theories of ethics attempt toanswer the same question in terms of obligations or moral duties, e.g., theTen Commandments. The ethical theory of rights makes the moral claims of theindividual central in situations of ethical conflict. Intuitive theories define what is ethical in terms of the dictates of the individual's own moral sense.

The growing need to contain health care costs has given rise to economic issues related to distribution of resources. For example, should governments spend more on approaches such as preventative medicine, homeopathy or naturopathic medicine? Should resources be concentrated on the young at the expense of the elderly? Will the introduction of managed care result in the dehumanization of medicine?

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