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Overview

What’s New in…. Medical Ethics

Mark Daniels describes the debates, the dilemmas and the philosophers who wrestle with them.

Medical ethics may have originated with the duties of the doctor laid down by Hippocrates in his famous oath. The relationship between doctor and patient was paternalistic, with the knowing doctor making choices in the interest of the ignorant patient. The oath, sworn by every doctor, remained remarkably unchanged for centuries, though it has been updated in recent decades (see box).

The Nuremburg trials after the Second World War threw medical ethics into the spotlight. How could trained doctors such as Josef Mengele do such terrible things in the concentration camps? What should be done with the data gathered during his horrific experiments? Should it be used in the benefit of humanity? Or burned out of respect for the dead and a desire to keep medicine untainted?

The Holocaust had a significant effect on the development of medical ethics. Nazi doctors had argued that the suffering of one group of people was justified by benefits to another group. In reaction to this, ethical systems stressing the rights of the patient gained ascendancy in medical ethics: the American doctrine of Natural Rights and Immanuel Kant’s ethics of duties. It was against this ethical backdrop that the development of medicine and its new technologies would be judged by popular opinion and by courts of law. Doctors thus find themselves considering questions of rights and entitlements when they make their more contentious decisions, and deciding whose rights will be privileged over the rights of others.

One of the first hospitals to receive a kidney machine, the Swedish Hospital in Seattle, USA, had such major problems with deciding who should be offered use of the new facility, and thus have their lives saved, that in 1962 they set up a special ethics committee. Since then, ethics committees have spread worldwide and become an established part of hospital life.

The scope of the subject and the search for theory

A number of themes permeate modern medical ethics and concern the relationship between doctor and patient: they involve the duty to treat, confidentiality and truthfulness. Other matters which have surfaced include: medical experimentation on humans with or without their knowledge, coping with public health emer-gencies, and the for-profit issue. Developments in technology have created a further set of problems. These problems have led to questions of the competence of the patient to make decisions when he or she is mentally deficient (in psychiatry), a child (in paediatrics), or as yet unborn (as in medical genetics).

These various matters are approached from a number of perspectives which include the philosophical: and decisions are rendered according to the arguments of rights-based ethics (Kantian), utilitarian ethics, or virtue-based ethics (Aristotelian).

To consider the example of abortion, the rights-based approach determines the rights of the mother and of the unborn baby and then tries to work out whose rights should prevail. The utilitarian approach attempts to weigh the happiness of the mother against that of the unborn child. A virtue-based approach considers how the woman understands herself and the sort of life that she wants to live; it then considers how the decision would affect that life.

There are other perspectives too: feminism is becoming increasingly influential with its criticism of the masculine nature of the doctor’s decision-making role. One school of thought, based on the approach of Carol Gilligan, advocates respecting differences and considering how people see themselves within their relationships with others. Each case is judged on different merits as perceived by the patient. Like the Aristotelian approach, this perspective considers not how the doctor should act, but rather how the patient should live.

A look at the medical ethics courses taught to doctors in the UK, Australia and the USA show that the only approach used to any extent is that of rights-based ethics. This approach, based on treating people as ends rather than as means through respect for their autonomy, has been taken up by a number of modern theorists such as Beauchamp, Childress and Engelhardt.

A popular modern theory, ‘mid-level principlism’ generated by Beauchamp and Childress (Principles of Bio-Medical Ethics, 1979), recommends four principles in whose light matters should be considered: beneficence (doing good), non-malevolence (doing no harm), respect for autonomy and, lastly, justice. These principles are based on a combination of a general duty-based ethic combined with a sort of intuition as to how medicine should be conducted ethically. This approach has been very influential and has been widely discussed. Cases where two or more of the principles collide are somewhat problematic, as is their choice of principles! Their definition of justice is also contentious.

It should not be concluded that Kant reigns supreme. While in the English-speaking world medical ethics generally has been duty-based, a number of specialised areas have been greatly influenced by other approaches: organ transplantation by utilitarianism and the treatment of the terminally ill by Aristotelian virtue ethics.

The search for general theories was castigated by Jonathan Glover is his seminal work, Causing Death and Saving Lives, published in 1977. He considered the shortcomings of the ‘Kantian’ reliance on rights – where there is much debate as to which rights actually exist and how one judges cases when rights collide. He also criticised both the Utilitarian approach, where such judgements are made in ignorance of what the resulting happiness will actually be, being at best educated guesses, and the Virtue-based approach, where the judgement as to what should be included in the list of virtues seems as arbitrary as the duty-based list of rights. Glover argued that the role of medical ethics was rather to consider the historic principles through which knotty cases had been decided and to try and unearth some coherent approach to making decisions generally.

Doctor-patient relations

Many of the questions concerning doctor-patient relations are old ones such as the problem of confidentiality. When a doctor discovers that a child patient has been sexually abused by its parents or that a young rake is merrily spreading about a sexually transmitted disease what should he do? The doctor frequently has privileged information and is torn between his duty to his patient and his duties as a law-abiding citizen.

One big change is that whilst doctors and patients were once quite happy for the doctor to make all the decisions, this has been replaced in the Western world with a paradigm of informed consent. Often, the patient has some knowledge, wants more information and demands to be involved in making the choices. This major change in attitude has led to a host of current concerns. For example, what of those who cannot give consent or whose decisions are possibly whimsical, such as children or people with mental problems? Attitudes to medical experimentation have changed, too, especially when the research is on animals.

The move from paternalism to informed consent has provided the grounding for another model of medical ethics, proposed by H. Tristram Engelhardt in the USA (The Foundations of Bioethics, 1996). He argues that in a morally fragmented world there are only four methods of resolving moral controversies. Three of these, persuasion/conversion, sound rational argument and force, do not work today. This leaves only one, agreement. This is similar to the medical notion of informed consent. Engelhardt’s model allows certain interactions that Beauchamp and Childress object to – such as approving of cases where people have to pay for their medical treatment! There has been a flood of papers and books either criticising Engelhardt or extending his principles to particular problems in medical ethics.

Birth and Death

The rights-oriented approach to medical ethics is particularly interesting when matters of birth-control, fertilisation and euthanasia are considered. Two competing approaches dominate the scene, both arguing strenuously in terms of human rights, but rooted in differing views of human nature. The ‘conservative’ view (held by many of the religious) is that human life is sacred and that it should not be terminated: hence abortions are frowned on, as are the activities of Dr Kevorkian (aka Dr Death) and his fellow euthanasiasts. The other, more liberal, view is based on metaphysical arguments concerning the nature of value. Only conscious beings ascribe value to things, and the worth of a human life depends on how the person whose life it is values it. There are no objective standards of such worth but obviously those who are conscious get to make the decisions. In the case of someone vegetating in a hospital bed hooked up to drips, the hypothetical decisions which that person might have made prior to their incapacitation are considered.

Arguments not based on human rights seem to be carrying little weight: thus the utilitarian arguments of the Australian Peter Singer have had little effect except as triggers for others to condemn the utilitarian approach. Singer argues that as regards the deformed unborn, the meagre happiness that might be gained during their lives would be outweighed by the loss of happiness by their parents or by others involved in caring for them. Such views have led to riots when he gives speeches in Germany. (See news item in Philosophy Now Issue 15).

Genetic Controls

With the continuing success of the Human Genome Project which is charting human DNA, scientists are acquiring the ability to genetically test for vast numbers of hereditary ailments such as Tay-Sachs disease, predispositions to various cancers and diabetes. Techniques such as pre-implantation genetic diagnosis (PGD) may be able to prevent baldness, birthmarks and make everyone six feet tall! (see p.18 for a full article on this).

The ability to perform such wondrous feats leads to questions as regards their appropriateness. To make decisions for someone whom you can consult is one matter. To make decisions for the unborn with severe physical defects is another. To make decisions regarding such trivia as height and baldness for people who will grow up in a society in several generations time, and whose values are as yet unknown, is exceedingly dodgy and the prospect has generated a rash of learned articles and books on the matter. The questions in this arena are profound: can anyone own the rights to the human genetic makeup? Can the DNA blueprint of people be revealed without their knowledge or consent? Should people be cloned – and should the clones be treated as people? Could one create brainless clones as spare-part holders in case of need? All sorts of gruesome and intriguing questions rear their ugly heads! In the UK the debate has intensified with the recent decision to allow research into cloning human tissue. Medical ethics is one of the few areas of where philosophers have a direct influence on government policy, with ethicists such as John Polkinghorne, Dame Mary Warnock and Onora O’Neill playing a prominent role on the various committees and advisory panels.

Afterthought

The development of medical ethics has been spurred on by the enormous strides in medical capabilities in the second half of this century. The great range of choices which nowadays are made routinely – and their potentially horrific consequences have had major consequences for doctors themselves. The ever-present reality of the law courts and the expensive consequences of litigation (and high insurance premiums) have impressed on even the most unethical doctor the importance of reaching appropriate decisions. The ability to spread the blame and involve others in the process – such as medical ethicists – has been a natural consequence of the modern age which has seen the traditional authority of many of the professions come under attack. Sartre and the existentialists have also had an influence: doctors are no longer expected to make the correct decision but rather hope to make the right sort of decision, after considering all the necessary factors and choosing to the best of their ability.

This article would have been utterly banal without the principled beneficence of Father Dr Cyril Barrett, Prof Alastair Campbell, Prof Jonathan Glover and Rabbi Dr Norman Solomon. Any faults are purely those of the author.

Hippocrates’ Oath

I swear by Apollo the physician, and Aesculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation- to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art. I will not cut persons labouring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional practice or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot!

Modified version: Declaration of Geneva (as amended at Sydney, 1968)

At the time of being admitted as a member of the medical profession:

I will solemnly pledge myself to consecrate my life to the service of humanity;

I will give to my teachers the respect and gratitude which is their due;

I will practice my profession with conscience and dignity; The health of my patient will be my first consideration;

I will respect the secrets which are confided in me, even after the patient has died;

I will maintain by all the means which are in my power the honour and the noble traditions of the medical profession; My colleagues will be my brothers;

I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient;

I will maintain the utmost respect for human life from the time of conception; even under threat, I will not use my medical knowledge contrary to the laws of humanity.

I make these promises solemnly, freely and upon my honour.

Finding out more

Beauchamp and Childress Principles of Bio-Medical Ethics, 1994 The great classic - 4th edition of the 1979 original.
H Tristram Engelhardt The Foundations of Bioethics, 1996. A current theory.
Gillon and Lloyd Principles of Health Care Ethics, 1994. A collection of papers applying Beauchamp and Childress mid-level principalism.
Seedhouse and Lovett Practical Medical Ethics, 1992 A brightly coloured and enjoyable guide for doctors. Ludicrously expensive.
Carol Gilligan In A Different Voice. A feminist approach.
Jonathan Glover Causing Death and Saving Lives, 1977. A readable approach to clinical issues. Peter Singer Rethinking Life and Death, 1994 Views of the great utilitarian.