Medical Ethics

Medical Ethics

1. Introduction to Medical Ethics

Medical ethics is a system of moral principles that apply values and judgments to the practice of 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. There is an extensive area of conceptual overlap between medical ethics, professional ethics, and bioethics. Medical ethics is the study of moral values and judgments as they apply to medicine. Bioethics is the broader study of the moral and ethical implications of new biological discoveries and biomedical advances, covering ground from animal research to gene therapy. Bioethics also includes the study of the more commonplace questions which arise in the primary care and general hospital setting, such as the rights and wrongs of informed consent, end of life care, and allocation of scarce resources. Clinical ethics is the application of ethics which are relevant to situations that arise in the setting of clinical medicine. Clinical ethics are a set of moral principles and articulated procedures that guide doctors and other healthcare professionals in the methods and processes of clinical care, helping them to decide the course of action when caring for the ill or injured. Medical ethics has its foundations in the Hippocratic Oath, which was a commitment made by physicians to uphold specific ethical standards. During the 20th century, especially after the end of World War II, much of the healthcare systems were regulated by modern medical ethics starting with the Nuremberg Code. During the waning years of the 20th century, not only did the regulation of research and development increase, the field of medical ethics underwent a massive expansion and has become an important part of medical curricula and continuing professional education.

2. Principles of Medical Ethics

Autonomy is a person’s freedom to live their life according to reasons and motives that are taken as their own. It is the reason why it is wrong to deceive someone as this involves making a decision based on false information. It is also linked with the idea of informed consent as a voluntary and rational decision. Autonomy is a principle that is often difficult to apply in dilemmas and medical practice and it may be outweighed by other principles in Beauchamp and Childress’s framework. It is however an important guideline for respecting persons and is clearly central to many issues in bioethics.

Beauchamp and Childress believe that using the idea of principles in medical ethics is a practical way to determine right from wrong. Given that these principles are used widely in the field and form the basis of principlism, it is useful to look at Beauchamp and Childress’s view in detail. They see principles in medical ethics as general norms for the conduct of moral action. This view is derived from the philosophical idea of principle as fundamental to practical reasoning and judgment. Principles are also used in an extended sense to cover practical guidelines for action which are conditional on particular values. This distinction is hierarchical; policy is derived from direction by principle and both are the expression and application of value. The principles approach that Beauchamp and Childress advocate is both a way to solve dilemmas and a means to judge the rightness of an individual act. Given principles’ significance for moral judgement, they are sometimes termed presumptive reasons. This means that they provide a reason to act in a certain way unless it is overridden by a more significant moral consideration. Principles therefore provide a framework for judgement and an order of priorities. The four prima facie principles are, according to Beauchamp and Childress: autonomy, beneficence, non-maleficence, and justice. Several other principles have been suggested in the literature but none are as influential as these four.

Principles in medical ethics are the starting points for various decisions in medical practice. A principle is defined as a rule of right conduct or a general truth. In general medical ethics, before principled decision making is applied, the facts are ascertained and the problems and options are identified. The next step is to sort through these options with the use of a principle (or principles). Although not all ethical decisions are reached through principled reasoning, the principles approach has been influential in bioethics.

3. Ethical Issues in Medical Practice

In the past, the usual practice was to treat the parents as having authority to make decisions concerning the child. In the case of medical emergencies and many conditions which pose little threat to the life or future health of the child, this is a reasonable presumption. But there are some treatments, particularly those of a preventive or psychiatric nature, which the child may be competent to judge as being against his interests, or as involving such a violation of his personal autonomy that it justifies his resistance to the point of seeking legal means to become an emancipated minor. It is difficult to frame rules concerning exactly when a minor is to be treated as competent to make his own medical decisions. But it is clear that as the competence of the individual minor increases, there should be a corresponding increase in the extent to which he is regarded as having authority to make his own medical decisions, and a decrease in the extent to which these decisions are to be overridden by his parents.

Prescribing contraception to minors, therapeutic abortion, sterilization, genetic engineering, treatment of incompetent patients, and euthanasia are medical procedures which have moral implications and at the same time pose special problems of competence and consent. In the case of the treatment of minors, who number not only children but also adolescents who are below the legal age of majority, questions arise concerning who is to be regarded as the patient, what conditions should be put on the giving of confidential medical information to parents, and what should be done in the case of disagreement between the minor and his parents over treatment.

4. Ethical Decision-Making in Healthcare

One of the best-known frameworks is that of Beauchamp and Childress. This is popular among educators because the broad categories used are very apt for analysis of dilemmas in the form of a checklist. Thus a kind of pro et contra analysis is possible leading to a conclusion. Beauchamp and Childress have identified the moral principles underlying a morally good human action: non-maleficence and respect for the patient are seen as primary precepts of the profession of medicine, since healing is a service to the patients’ interests. By promoting what is good for the patient (beneficence) and acting in his interests (autonomy), this will lead to a resolution with the greatest balance between good and harm. The wide variety of principles and application to diverse cases does, however, make any algorithm derived cumbersome. Influences have come from the human rights sector with advocates of theory based on justice and the redistributive nature of healthcare, and these have undoubtedly become more relevant in an age of advocacy and litigation in medicine. A recent model proposed by Hope et al strives towards simplicity and applicability with the essence of an effective decision made between a two-person dialogue involving stating and critically testing a proposition, then deciding an action. This does, however, lack detail on process.

At the heart of bioethics education is the goal of assisting healthcare professionals to make sound ethical decisions. Most of us have an intuitive but insufficient understanding of what decision-making entails. Some literature is available which is helpful, although often less applicable to the complexities of everyday clinical practice. An adequate model for ethical decision-making should be able to account for the uncertainties inherent in healthcare, the need for flexibility in approach, the many and varied participants in the process, and the fact that the effects of decisions are not always predictable.

5. Future Challenges in Medical Ethics

Consider a recent scenario from the United Kingdom. Young parents bring their son to the family physician. He has a simple viral infection, but the parents are very anxious and the father says he cannot take more time off work to look after the child. The physician faces the strong temptation to prescribe antibiotics, knowing that they will do little good, but feeling that this might be the least bad way of responding to the social situation of the family. At the moment, this is a moral case with a right and wrong answer, and the physician has a duty to do the right thing. Now consider the same situation, but antibiotics have just been developed that can be given once as a cheap injection, by community nurses. This changes the situation completely. The physician doing the same as before would now be doing the wrong thing, but the solution is not just to have him act more virtuously. We need to know how the physicians act can be ensured that resources saved on antibiotics the doctor has no role in the decision about and how it can be decided, in a way that respects the healthcare rights of the family, ultimately leading to the parents doing the right thing for their child. These are issues about the right and wrong clinical and social policy, and they are collective issues to be addressed by a changed medical ethics.

That distinction, however, may not last. Firstly, the traditional role of bioethicist may vanish with many clinical researchers simply becoming ethicists as they struggle to work out the right thing to do in areas of genetics or health policy. More significantly, many of the new ethical challenges in health will not arise in special cases, but in the attempt to keep doing the right thing in conditions of severe resource constraint and amidst fundamentally changing doctor-patient relationships. The latter are issues for all doctors, and hence issues for medical ethics as a whole. For these reasons, it is arguable that tomorrow’s doctors will need to be tomorrow’s ethicists, and that the proper task of medical ethics is nothing less than to secure ethical health for society.

In closing, we would like to consider some of the very important future changes in healthcare as a way of looking at the challenges for those involved in clinical ethics. We want to focus not so much on the new ethical issues arising from technological or other medical advances, but on changes in the healthcare ‘system’. One influential interpretation of clinical ethics has been to see it as something that only happens in a particular kind of special case; bioethicists, in this view, are people who consider the ethical issues thrown up when medical research impinges on human subjects, or physicians face difficult decisions about prolonging life or organ transplantation. This way of seeing matters is closely connected with the historic rise of medical ethics as a distinct discipline from bioethics.

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