Medical ethics is a required element of an American physicians' formal training. Familiarity with ethical principles on a basic level is necessary to pass initial medical licensing examinations. However, most physicians are unable to elucidate specific ethics principles, explain how or why medical ethics principles have come to be, or integrate and prioritize medical ethics principles systematically.
Many different medical ethics guidelines are available, such as from the American Medical Association (AMA), American Osteopathic Association (AOA), and American College of Physicians (ACP). The AMA code is of historical interest since it originates from the world's first medical ethics code (written in 1847) intended to function at a national level.
Although the AMA advertised its updated 2016 code as "designed to meet the ethical challenges of medical practice" and as "the medical profession’s authoritative voice," the first page of this code states that the code only contains opinions and is "not intended to establish standards of clinical practice." Other codes frequently contain similar such disclaimers. Given the lack of definitive ethical standards and premises, let alone a hierarchy or algorithm for prioritizing them, physicians often still face great challenges in achieving satisfactory solutions to ethical challenges for themselves, their patients, and other parties involved.
This article has the following goals for its practical application by physicians:
The first recorded systematic approach to defining moral behavior (ethics) belongs to Aristotle (384-322 BCE). He referred to his work as the "ethikos," which means the "customs." The word denotes the concept of "habitual character and disposition." Multiple other Greek writers (such as Thucydides (c. 460-400 BCE), Plato (c. 426-347 BCE), and Luke (c. first century CE) use its root. The word ethics was first used in the modern sense in the 1300s. Thus, although a literal interpretation of "ethics" is the study of what character traits or dispositions are already habitual and not what ones should become so, the term morphed into the latter meaning in common parlance centuries ago.
Aristotle lectured on ethics with practical intent, specifically to improve the quality of human lives. His principal concern was the nature of human well-being.
Evolution of Ethics
Ethical evolution, like the evolution of many other disciplines particularly the field of law, often starts as a reaction to a new event (a human action or inaction) that an author considers unacceptable. Although the action/inaction involves specific circumstances (such as time, place, and views of the people involved), the reaction attempts to establish that the action/inaction shall thenceforth become unacceptable for others in circumstances potentially very different from the original event.
Many factors, such as economics, affect a society's ethics, in particular, a feedback loop (akin to a yin-yang) with law and other forms of enforceable policy. Ethicists' views that policymakers support eventually lead to policy. Policy eventually leads to a dilemma, then a reaction to the dilemma, and then a new or revisited commentary by ethicists regarding what action or inaction is acceptable. The cycle repeats. This evolution of ethics and law results in a potential source of physician conflict, such as when a physician trained in more current ethical concepts and policy disagrees with a physician who believes in more dated ones (e.g., paternalism).
Theoretically, an ethical principle always follows a traceable line of historical events and persons that have prevailed in influence. Looking at the history of an ethical principle (or law) can provide an understanding of why the ethical principle has risen to prominence (or why a law exists) and may enable a practical basis for accepting or rejecting it. Medical ethics principles evolve intertwined with principles in other fields of ethics.
Ethics as a Systematic Study
Ethics comprises numerous overlapping subdisciplines. Medical ethics can be classified as a subdivision of applied ethics, but it functions dependently on the following subdivisions as well (this list is not intended to be all-inclusive):
Just as applying knowledge in a branch of surgery can improve by understanding aspects of other surgical disciplines, the application of medical ethics can be improved by understanding aspects of these other ethical subdivisions. Conversely, limited awareness can set up a physician to conclude that "there is no right answer" to a situation even when a confident best answer could otherwise emerge. For example, it was a grasp of Aristotle's non-medical virtue ethics from the 300s BCE that enabled Thomas Aquinas (1225-1274; not a physician) to propose the extremely practical Principle of Double Effect, which is used frequently by doctors today.
When, where, who, and what are relatively easy questions to answer. How and why are the harder questions. Metaphysics, epistemology, history, and the "hard" sciences address how. Ethics, theology, and logic, in their most ambitious form, also attempt to address why.
Without the exploration of the why, a physician has limited ability to apply ethical concepts to new, varied, and complex situations. Physicians who truly want to understand and apply ethics must be simultaneously like a child repeatedly asking the next why and the teacher continuing to find an answer.
Authority in Ethics
An explanation for "why" that adults give children is "because I said so." This suffices only if the child holds the adult to have a satisfactory position of authority. It is practical when having a dialogue with yourself, with patients, or with others regarding what is or is not ethical to share and apply the written and unwritten opinions of all the relevant authorities to reach a satisfactory consensus. A shortcut to not having to think through an ethical dilemma is to refer to what a common/shared authority has already said. The following list, from laws to policies, serves as a relative weighting of authority on medical policy (in decreasing order) for American physicians that may help a physician determine a course of action.
Unless persons agree on the same authority, either in general or in a particular circumstance, they tend to find it difficult to agree on what is the right thing or best thing to do and what is not. Each applies principles from his or her accepted authorities that conflict with the authorities adhered to by other individuals. Therefore, "experience" or "years in the business" is not always the way to achieve the best decision in ethics as in science (where "experience" is the worst level of evidence.
Thomas Hobbes (1588-1679), the "father of Western political philosophy," discussed the function of authority in society. Though some of his ideas spurred the creation of the United States (e.g., inalienable rights), America's founding fathers rejected Hobbes' idea that government can have absolute power, preserving the "self-evident" truths that
In a real ethical dilemma, if none of the authorities listed above provides what seems to be adequate guidance, then physicians should turn to authority from the Great Conversation. The Great Conversation refers to how voices of the past, like Aristotle and Hobbes, influence people of later generations, which includes practical matters affecting the health care of millions of people today. For example, Harry Blackmun (1908-1999), the justice writing the majority opinion in the 1973 Roe vs. Wade trial, justified his decision to all the world, not based primarily on prior American law, but based on the views of Aristotle, Plato, and Jewish and Christian non-scriptural/post-scriptural writers. Further demonstration that law is not always the highest authority in medical ethics: the ACP code of ethics committee, which an attorney chairs, states, "Medical and professional ethics often establish positive duties (that is, what one should do) to a greater extent than the law."
Medical Ethics and Objectivity
On the one hand, Aristotle stipulates that an all-encompassing system of ethics cannot be condensed to precise proofs that demonstrate that an action holds true in every situation. On the other hand, he states that some actions should never be taken (exemplifying a doctrine of objective ethics, discussed below). Returning to the comparison of ethics with the law, a functional ideal of the American legal system is to maintain impartiality both when selecting and when enforcing standards that derive from meta-ethics and normative ethics.
Ethics and Science
On the one hand, ethics can gain credibility by borrowing methods from science. Some hypotheses and patterns in ethics can be studied using the scientific method. Persons can be exposed to an independent variable in a randomized fashion. The dependent variable of persons' moral decisions can be assessed. To a degree, beliefs and behaviors of persons can be quantified. Objectivity is a goal shared by science and ethics (discussed below).
On the other hand, "science" can be a hindrance to the original goal of ethics (i.e., to improve quality of life). This is a common theme in science fiction movies and battled against with laws and policies (such as that of the AMA). Setting aside the intent of science and contemplating the method only, the latter also may be of no aid. Sometimes the scientific method explains an observation, but often it does not and results in more questions than answers, similar to what can occur when mulling over an ethical dilemma. The scientific method may not prove that one theory or course of action is superior over another. How a scientist develops and conducts an experiment is subjective and variable. How scientists interpret and apply facts varies. Much of the work passed off by persons labeled as "scientists" is observational (i.e., it does not apply the scientific method at all) or violates David Hume's (1711-1776) is/ought problem, which warns against laying out observations using descriptive terms and then concluding with unsubstantiated prescriptive terms.
So-called objective ethics (also called ethical absolutism but distinct from "objectivist ethics" or "ethical objectivism") is the attempt to create a set of ethical rules that (almost) always holds true. For an ethical behavior to be truly objective, it must not depend on values or beliefs but only on reason and observable true statements. An observable true statement is one that can be shown to be true in the way the sentence "the sun is larger than the earth" can be shown to be true. Epistemology is the study of how a person can know something is true and is beyond this article's scope.
Ways to improve objectivity in medical ethics:
These methods (among others) are also used to formulate laws. The more real-world variables included and the less like a vacuum or a controlled laboratory environment an ethical dilemma is, the less the actual outcome may resemble the expected outcome. For an ethical system to be practical, it must be able to address variables and specific situations without a de novo analysis each time. It must also prevent extreme variety in outcomes by clinicians reaching different conclusions in identical situations.
Though it is not possible that normative ethics can be completely objective in the real world, attempts at maximizing objectivity can still be made.
Ethical Spectra and Biases
It is important when evaluating the stance of an authority to understand both its biases and if it has one, its primary objective standard (as defined above). For example, think about how differently doctors of different specialties might approach fever workup and treatment due not sharing a reference standard:
The AMA code of ethics originators themselves can serve as an example of bias in ethics. The formation of the AMA occurred, at least in part to (1) to prevent economic competition from "less qualified" medical practitioners and (2) to define the obligations of the public to doctors, while doing nothing to unbar racial minorities and women from practicing medicine.
Listed below are the spectra (biases) of the different major Conversationalists in ethics (not intended to be all-inclusive). Awareness of these can help a physician perceive the variety of ethical views he or she will encounter from patients, colleagues, and others.
Theories of Ethical Standards
Medical ethics has included each of the above standards to different degrees in different times and places, and a detailed discussion of the associations is beyond this edition of this article. However, physicians practicing medical ethics, from its ancient historical roots (in Egypt, Mesopotamia, and Greece) through the present day, have always primarily adhered to ethics of deontology, i.e., duty.
The number of included duties is not magical or sacred. It differs depending on the source. Thomas Beauchamp (1939-) and James Childress (1940-) emphasized four, preferring to call them "principles" instead of "duties:"
Bernard Gert (1934-2011), Charles Culver (1934-2015), and Danner Clouser (1930-2000) provide a critical alternative to Beauchamp and Childress, both on a philosophical and on a practical level, but also make many similar conclusions. They emphasize 10 duties for physicians:
Not altering Beauchamp and Childress' duties per se but also hoping to improve upon the practicality of their analysis, Albert Jonsen (1931-), Mark Siegler (1941-), and William Winslade (1941-) identify four topics intrinsic to every clinical encounter for organizing and prioritizing facts of a particular case:
The ACP ethics code includes Beauchamp and Childress' four principles by name. The 2017 AMA code defends all four principles to varying degrees. It does not address non-maleficence and beneficence using those terms but advises physicians to behave in such a way that maximizes patient benefits and minimizes harm. As mentioned previously, it emphasizes beneficence: "The practice of medicine... arises from the imperative... to alleviate suffering." The section on organ procurement supports distributive justice.
While maintaining deontology as a basis, the AMA code shifted from using the language of “duties of physicians” in 1847 to “principles of medical ethics” in 1957, still implying that medical ethics is by nature shaped predominantly by duty (as opposed to by virtue or utilitarianism).
Conflicts in Medical Ethics
Conflicts of interest in carrying out the duties are inherent to the profession and are the norm, not the exception. Conflict can occur between essentially any two ethical principles or duties. Numerous medical ethics texts explore these conflicts for a given clinical scenario, particularly conflicts between autonomy and beneficence, between distributive justice and beneficence, and between the "lesser of two evils aspect" of beneficence and non-maleficence. Instead, the rest of this section will examine a much less commonly addressed conflict between beneficence and non-maleficence: not which is the lesser of two evils, but which is the greater good, which is more fundamental to the practice of medicine.
Beneficence is a Greater Good than and Primary to Non-Maleficence
Although non-maleficence serves as "out-of-bounds lines" in medicine, beneficence should remain cemented as the goal. This view directly opposes that of Gert, who argues that a physician has no moral obligation to be beneficent other than to meet whatever minimum duty of beneficence is required of the physician to keep his or her job. He argues that non-maleficence is morally obligatory, but that beneficence of any kind is not. Gert was a very rational thinker but was neither a physician nor a student of medical history, never delving into what doctors of the past said in the Great Conversation. Gert's view contradicts that of thousands of years of medical practice, the current AMA position, and many people's (both doctors and otherwise) moral compass as directed by their spiritual/religious convictions (discussed below).
The 2017 AMA code of ethics' opening line (i.e., its version of "Four score and seven years ago our fathers brought forth on this continent a new nation..." or "When, in the course of human events, it becomes necessary for one people to dissolve the political bonds which have connected them with another...") is:
"The practice of medicine, and its embodiment in the clinical encounter between a patient and a physician, is fundamentally a moral activity that arises from the imperative to care for patients and to alleviate suffering." (AMA code 1.1.1, 2017).
The text continues in the same vein about putting patients' health above that of the physicians' needs. There is no mention of any notion pertaining to "do no harm" until Section 1.1.7, and the authors of the first chapter never fully develop the idea of non-maleficence. That the primary purpose of doctoring is altruism is supported by the Hippocratic Oath, in which "I will use treatment to help the sick according to my ability and judgment" precedes a discussion of avoiding harm. The concept "first do no harm" dates to Auguste Francois Chomel (1788-1858).
The mainstream perspective of natural law theorists, psychologists, and the public is that humans normally are expected to exhibit some beneficence (altruism). The controversy in law, philosophy, and business is how to defend rationally the degree to which beneficence is required.
An attempt to create an objective formula for when some human attempt at beneficence should be expected is:
A person (or group of people) P has an obligation to perform an act of beneficence aB to some other person Op whenever:
Contrary to Gert's assertion that such behavior is not morally rational, this kind of behavior is supported by moral teaching in the form of a command, e.g., the parable of the Good Samaritan (Luke 10:25-37)..."Go and do likewise."
The notion that business persons' economic motivation commonly trumps altruism is testified, not only by anyone who has ever "been taken advantage of" or "not had adequate service" by a business but also in the philosophy literature. Hume advanced the ethical theory of emotivism, which is that ethics claims are based on emotion, not on fact. Adam Smith was Hume's successor and influenced the field of business ethics. Smith (1723-1790) argued that the well-being of persons depends on social cooperation but not on businesses' benevolence to customers and that it is nonsensical to expect businesses to show benevolence. However, William Nickels (1939-) and Kellie McElhaney (1966-) have provided contemporary arguments that "charity" and "social responsibility," both forms beneficence, are usually good for business in the long run
Persons like-minded to Gert believe beneficence is nothing more than commendable. Some physicians share this view or some version of it; their obligation is only to make some minimal effort to prevent harm but not even to attempt to relieve suffering. Physicians tend to exhibit this behavior/view as they evolve from their early days in medical training and obtain positions in which they are more concerned with money. Businesses and/or physicians in authority that embrace the mantras of Smith and Gert not uncommonly go so far as directly to impede other physicians from carrying out the altruism that inspired them to become physicians.
The medical and military professions are both based on the ancient Greek virtue of "arete"- a commitment to excellence. Whereas the duty of the soldier is always foremost to protect his fellow soldiers, the duty of the physician is always foremost to protect the patient. Persons who enter these professions often feel a "higher" calling to serve others that compels them to serve beyond meeting a minimum standard. Gert was married to his childhood sweetheart for over 50 years before being separated by death. Although a union of that sort can be achieved out of "duty," it usually requires and derives its meaning from another fundamental trait of humanity that can also be the driving force of a physician's behavior: love (Greek "agape").
Gert convincingly argues that a person cannot impartially do good for all persons at all times. In this way, he unintentionally promotes distributive justice. Nevertheless, it is essentially unheard of to find a member of the Great Conversation, a statute of law, or an ethical code pertaining to the practice of medicine that argues that distributive justice dominates beneficence as a rule. Instead, the beneficence-justice dilemma is discussed only in the context of emergencies.
Unfortunately, Gert does not define how to carry out duty practically when there are opposing forces, specifically, duty to the patient, to the nurse, to one's colleagues, to one's administrator, to one's medical student, and to one's risk manager. Codes of medical ethics indicate that the physician's duty to the patient supersedes the physician's duties to all others. Gert agrees that individuals running a health care organization should optimize physicians' time spent for beneficence while still meeting expectations of patients and policy requirements by the effective use of mid-level providers, for example, reduce physician time spent on tasks not required for a physician to accomplish, such as patient education, data gathering, correspondence, procedure organization, and other logistics.
Proposed Hierarchy of Beneficence, Autonomy, Non-Maleficence, and Justice
Do what you believe is good for the patient assuming that the patient agrees there is not a better option (beneficence and respect for autonomy).
If the patient does not agree your plan is the best option, then stop (respect for autonomy).
If someone wants you to act in a way that you know could harm the patient, then stop (non-maleficence). The exeption to this is if the intent of the action that could harm the patient is beneficence and if the patient agrees the action is the least threatening/most desirable means to an end available (respect for autonomy), then proceed.
Ration beneficence evenly among patients (distributive justice); otherwise, it is the same as for non-emergency setting.
Although successfully performing each of these tasks to the satisfaction of every patient is impossible, the AMA states the physician must make a good-faith attempt.
Medical Ethics' Link to Theology and Religion
Whereas writings on morals extend historically to the Egyptians before 2000 BCE, the field of normative ethics began to act independently from the field of theology only around the mid-1700s. In other words, only in the last 5% to 10% of history has the approach to the public dissemination of mainstream moral thought involved taking God out of the equation; a similar mainstream approach in medical ethics dates to an even later time. The major Greek philosophers (Aristotle) and Hippocratic physicians believed in a higher power than humanity. The 1847 AMA code drafting committee chairperson Dr. John Bell (1796-1872) wrote that "medical ethics, as a branch of general ethics, must rest on the basis of religion..." Dr. George Wood (1797-1879), AMA president in 1853, advised every physician to have access to the AMA ethics code because "next to Holy Scripture and the grace of God, it would serve most effectually to guard him from evil."
In 2017, over 70% of Americans identified as belonging to an Abrahamic religion (Christianity, Islam, and Judaism). About 2% identified as belonging to one of the other two major world religions of Hinduism or Buddhism and about 6% identified as atheist or agnostic. At least approximately 20% of American hospital beds remain in a religious hospital.
None of the primary principles of medical ethics either began with or are unique to Abrahamic writers, and the norm in the United States is now enforcement of moral principles by secular authorizing bodies (government, professional societies, places of business). Nevertheless, it is historically inaccurate and incomplete to neglect the influence of a belief in God on the establishment of these principles, as illustrated by Friedrich Nietzsche. An informed application of the imperatives that modern medical ethics codes still prescribe cannot exclude concepts in monotheistic theology and theodicy. American physicians routinely encounter patients and family members who ascribe authority to texts they believe come with directives from God, which often serve as their highest authority.
Aristotle envisioned ethics as a means for the improvement of human life, in concert with the practice of medicine. He pointed out that without having a standard for knowing what the right reason is, a person cannot master ethics, just as a student of medicine cannot master medicine if they can only say that the right treatment to administer is one someone else told them to administer but can name no standard other than this.
Medical ethics remains an evolving field. Its application using a system of principles is relatively recent. The first code of medical ethics was written after the inventions of antiseptic technique and the stethoscope and around the same time as the invention of general anesthetic. In 1980, the AMA reduced its code of ethics from its original four chapters extending for 20 pages to seven minimally elaborated principles. By this time, state legislatures and the hospitals had taken over the doctors' political agendas that were a significant part of the original concern of the AMA. Not yet had ethicists' reactions to the civil rights movement of the 1960s and 1970s and the medical technology revolution of the last half of the 20th century taken effect at the level of the AMA. In 1998, for the 150th anniversary of the original code, the AMA re-expanded the code to nine chapters over 150 pages. In 2017 the AMA further expanded the code to eleven chapters spanning over 200 pages.
Article IV of the 1980 AMA Code added the language of "patient rights:"
"A physician shall respect the rights of patients, of colleagues, and of other health professionals."
The 2017 code expanded patient rights to a whole page. Patient rights are still not a national uniform doctrine. The United States Congress proposed and then rejected the concept of making it so in 2002, but it may be the next medical ethics horizon that is crossed in the United States.
Medical ethics continues to expand in terms of authorship and scope. By 2017, twelve journals indexed in PubMed that are devoted to medical ethics had reached a citation index factors of at least 1.0, such as The American Journal of Bioethics, BMC Medical Ethics, Journal of Medical Ethics, Bioethics, and The Hastings Center Report.
Primary research and review articles continue to discuss new concepts in the ethics of issues such as:
And as with Henry Beecher's reports in 1966 that marked a turning point in the United States' government's involvement in medical ethics, ethics applications in clinical trials also continues to evolve.
The field of medical ethics will continue to impact the fields of law (with new medical ethics-based laws passing yearly across the states) and science. In turn, these fields will continue to impact medical ethics. Physicians must not lose sight of changes that have occurred recently and that are yet occurring in order to practice medicine according to modern principles of medical ethics.
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