Continuing Education Activity

A team of collaborating professionals now manages patient care. This model provides coordinated, cost-effective, and high-quality health care. Ethics serve as the guiding principles for healthcare professionals, ensuring that they prioritize their patients' well-being, treat patients with dignity and respect, and foster trust and confidence in the healthcare system.

Numerous medical ethics guidelines from medical societies, other healthcare organizations, and government agencies are available. However, variability between them only raises questions about which rules are essential and which are not. Understanding the origins of and a way to apply medical ethics principles systematically will help healthcare professionals develop a defensible hierarchy or algorithm for prioritizing the principles from among these various organizations' guidelines. This topic discusses the current understanding of the origins and development of medical ethics and emphasizes the pivotal role of interdisciplinary teams in applying these principles to patient care.

Objectives:

• Apply medical ethics principles to real-world clinical scenarios, demonstrating proficiency in ethical decision-making.

• Differentiate between ethical principles, discerning their relevance and significance in specific clinical contexts.

• Select and apply appropriate ethical frameworks and principles based on the unique aspects of each clinical scenario.

• Collaborate with the multidisciplinary healthcare team to ensure cohesive ethical decision-making and consensus in patient care.

Introduction

Determining the ethical nature of an individual's actions within a specific society is primarily contingent on the prevailing standards of morality at the broadest level of that society. Consequently, when making an ethical decision, the most appropriate action is to consider the overarching and enduring principles that influence society the most. Three significant physician associations in the United States and Canada have issued medical ethics guidelines applicable to various medical specialties:

• The American Medical Association (American Medical Association Council on Ethical and Judicial Affairs. AMA Code of Medical Ethics. American Medical Association; 2017);
• The American Osteopathic Association (American Osteopathic Association; 2016. https://osteopathic.org/about/leadership/aoa-governance-documents/code-of-ethics/. Accessed November 4, 2023); and 
• The American College of Physicians.[1]

The American Medical Association (AMA) code, established in 1847 and officially published 1 year later, marked the world's inaugural medical code of ethics designed to be universally applicable to all physicians nationally.[1] The contemporary version of the AMA code delineates a hierarchical framework for the appropriateness of actions and the levels of obligation, employing terms such as "must," "should," and "may" (American Medical Association Council on Ethical and Judicial Affairs. AMA Code of Medical Ethics. American Medical Association; 2017).

Based on their respective fields, not all healthcare professionals (HCPs) must uphold the policies in the AMA code, and the existing ethics codes fail to encompass all situations routinely encountered by HCPs. Due to the absence of globally definitive ethical standards and algorithms, HCPs often confront uncertainty when grappling with ethical dilemmas involving themselves, their patients, and other stakeholders. A pressing need exists for comprehensive resources to assist all HCPs in discerning the most ethical courses of action.

Issues of Concern

Before tackling a medical ethics dilemma, clinicians should understand 5 background issues regarding the position of medical ethics within the larger ethical landscape.

1. Origins and Types of Ethics

Understanding the history of something provides valuable insights into its current state. Ancient moral instructions can be traced back to Egyptian writings before 2000 BCE (Morenz S. Egyptian Religion. Cornell University Press; 1973).

 The earliest recorded systematic effort to justify a set of ethics through logic belongs to Aristotle. (384-322 BCE) (Aristotle. Nicomachean Ethics. 1.1094b, 2.61106a, 6.11138b18-34). Aristotle uses the term ηθικoς or ethikos to encompass the concepts of customs, habitual character, and personal disposition. Many other ancient Greek writers, including Thucydides (c 460-400 BCE), Plato (c 426-347 BCE), and Luke (c first century CE) also used this term. A biologist and jurist, Aristotle aimed for practicality in his philosophical writings, aspiring to outline a system that contributes to individual and societal well-being (Aristotle. Politics. 1295a36). This pragmatic approach influences mainstream ethical codes, which grapple with balancing personal and societal interests.

Ethics now encompasses a complex landscape with numerous overlapping subdisciplines. Medical ethics is a subdivision of applied ethics, drawing from other subfields. The following is a list of some pertinent ethics subfields: 

• Descriptive or behavioral ethics: Asks how people behave in the real world. What psychological processes limit their ability to behave consistently compared to how they say people should behave?
• Normative ethics: Asks how ought people to behave and why?  
• Meta-ethics or meta-physics: Asks the rules for deciding how to judge behaviors. How can people determine whether judgments on good versus bad behavior are facts or are just opinions?
• Applied ethics: Refers to the application of ethics to real-world problems. What practical, systematic approach allows a person to apply descriptive, normative, and meta-ethics conclusions to real-life situations?
• Group ethics: What factors enable and inhibit individuals working together to do good? What behaviors yield the greatest likelihood of prosperity for a particular group?

In the field of surgery, understanding aspects of other surgical disciplines can improve the practice of a singular surgical specialty. Similarly, medical ethics can improve by understanding aspects of other subfields of ethics. Conversely, having limited awareness of non-medical ethical principles may prompt a healthcare professional to conclude that "no right answer exists" in a situation where a confident answer can emerge. For example, by understanding Aristotle's ethics, Thomas of Aquinas (1225-1274) was able to propose the principle of "double effect," which is the principle that most American state legislatures still use to outlaw physicians from directly ending other people's lives for euthanasia.[2][3]

While "How?" and "Why?" pose more challenging inquiries, questions such as "When?," "Where?," "Who?," and "What?" are relatively straightforward to answer regarding a topic, metaphysics, epistemology, history, and the "hard" sciences address the how aspect. Issues within epistemology, a field focused on determining how one can ascertain the truth, exceed the scope of this article. In their most ambitious forms, ethics, theology, and logic also endeavor to address the why.

Without delving into the why, healthcare professionals possess a limited capacity to apply ethical concepts to novel, diverse, and intricate situations. Healthcare professionals aiming to comprehend and apply ethics must adopt a dual role, akin to a child persistently asking "Why?" and a teacher consistently furnishing a coherent response for each new question.

2. Evolution and Cycles of Ethics

Examining the historical context of an ethical principle or law can provide insights into its origins, influence, or shifts in prominence. The dynamic development of ethics and policies may give rise to conflicts among healthcare professionals. For instance, disagreements may arise when a healthcare professional, trained to prioritize contemporary ethical concepts like respect for patient autonomy, clashes with a clinician adhering to more traditional principles such as paternalism.

The evolution of ethics, much like the progression of laws and various disciplines, often stems from the influential expression of an opinion, deeming a specific event unacceptable. Although specific circumstances, including a particular time, place, and the perspectives of those involved, may be tied to the initial event, the written opinion typically strives to declare that the action or inaction should be considered unacceptable in potentially diverse situations distinct from the original event.

Numerous factors, such as economic conditions, influence a society's ethics. During economic prosperity, 1 set of ethics may be applicable, whereas, in times of economic adversity, a different set of ethics might prevail. Additionally, individuals' societal roles contribute to the ongoing establishment of ethics through a feedback loop. Ethicists express their perspectives on various circumstances, and policymakers may eventually endorse some of these views. The implementation or misuse of these policies then creates new dilemmas, prompting ethicists to initiate a fresh cycle and provide new or reconsidered commentary on actions or inactions deemed acceptable.

Several ethicists have attempted to maintain a clear distinction between the process of discerning good and bad, which is the essence of ethics, and the differentiation between right and wrong, often referred to as "morality." The latter term implies that decisions may have consequences in an afterlife. Notable exceptions to this separation include early Western ethicists like Plato, who integrate piety into ethics (Plato. Protagoras. Chapter 5).

In Western civilization, a systematic effort to fuse ethics with morality began in the 1300s CE with Thomas of Aquinas, whose writings continue to influence medical and non-medical ethics today (Aquinas T. Summa Theologiae. Part 2. Question 64, article 7). David Hume (1711-1776) introduced the "is-ought problem," cautioning against drawing conclusions based on descriptive terms and then making unwarranted assumptions using prescriptive terms (Hume D. A Treatise on Human Nature. Book 3. Jonathan Bennett; 2017: 234-242). In essence, Hume advocated against illogically defining "what should be" and urged a return to the emphasis of early Greek ethicists who determined good or bad based on "what is." Hume's ideas inspired Immanuel Kant (1724-1804) to articulate a rationale for moral rightness solely based on intrinsic merit or logic, divorcing it from religious considerations (Kant I. Critique of Pure Reason. 1781. Section 1). Kant's concepts persist as the standard for the logic-based application of morality in Western society.

The early 1800s witnessed a reaction to Kant, giving rise to the third dominant approach in modern medical ethics, consequentialism. In the twentieth century, behavioral ethics emerged. Behavioral ethics is a field that integrates principles from psychology and the scientific method with ethics. Psychologists in this field have revisited Hume's perspective, contending that people's actions are predominantly influenced not by logic but by emotion.

Further exploration of the evolution of the AMA ethics code will ensue later in this article. The code has undergone significant changes, becoming so extensive that the AMA no longer publishes complete periodic revisions. Instead, it revises the code with new opinions, topic by topic, on an ongoing basis.

3. Authority in Ethics

An explanation for "Why?" that adults give to children when the adult does not have a cogent answer is "Because I said so." This explanation only suffices if the child accepts the adult to hold a satisfactory position of authority. To reach a consensus when having a dialogue with patients or others regarding what is or is not ethical, individuals must consider the opinions of all the relevant authorities, not just the most immediate, one-level higher authority. Selecting the most relevant authority for all parties can serve as a shortcut to a conclusion by eliminating the need to build an argument from scratch. The following list is a relative weighting of secular authority in decreasing order that may help a healthcare professional determine a course of action:

• Federal government law 
• State government law 
• National policy issued for all HCPs regardless of type of HCP  
• National policy issued for a specified type of HCP 
• Local policy issued for all HCPs regardless of the type of HCP  
• Local policy issued for a specified type of HCP 
• Healthcare organization's ethics committee
• Healthcare organization's employees according to hierarchy on the organizational chart

However, mindlessly following this order enables people to justify supporting corrupt situations like medical experimentation on minorities.[4][5] The current AMA code stipulates: "In exceptional circumstances of unjust laws, ethical responsibilities should supersede legal duties" (American Medical Association Council on Ethical and Judicial Affairs. AMA Code of Medical Ethics. American Medical Association; 2017).

Some consider religious laws to hold higher authority than secular laws, as discussed below. In an ethical dilemma, if none of the authorities mentioned thus far provide adequate guidance, then HCPs can turn to authorities from The Great Conversation, who first explain the normative ethical principles relevant to the dilemma. The concept of the Great Conversation encompasses the enduring relevance of ideas proposed by historical figures such as Aristotle or religious leaders. These ideas, proven to hold across different times and locations, remain pertinent to contemporary healthcare issues (Hutchins R. The Great Conversation: The Substance of a Liberal Education. Encyclopædia Britannica; 1955). For example, Harry Blackmun (1908-1999), a justice of the United States Supreme Court who wrote the majority opinion in Roe v Wade 410 US 113 (1973), justified his decision to rescind a law not based primarily on prior American legal decisions but based primarily on translations of Aristotle, Plato, and post-Biblical Jewish and Christian writers. 

4. Ethical Biases and Perspectives

The initial AMA code of ethics illustrates a biased approach to ethical standards. The formation of the AMA, driven partly by the desire to monopolize economic opportunities and restrict economic competition from healthcare professionals deemed "less qualified," involved self-selection of obligations to the public without seeking broad public input. Furthermore, those in authority intentionally took measures to impede the pursuit of careers in medicine by racial minorities and women. (Jonsen A. A Short History of Medical Ethics. Oxford University Press; 1999).

Various biases provide diverse perspectives for making ethical decisions. When assessing the position of an individual or committee as an authority, one must comprehend the primary objective standard that guides that person or committee. The following is a list of commonly used ethical standards:

• Egoism: Serve onesself first.
• Altruism: Serve others first.
• Cultural relativism: Serve one's society’s or other social group's expectations first.
• Subjective relativism: Let each person decide for oneself what interest to serve.
• Virtue ethics: Select and follow a defined list of virtues. 
• Duty or deontological ethics: Act based on the best intention alone, following a predetermined rule.
• The act is morally obligatory. 
• Do not calculate the odds of achieving the desired outcome.
• Adhere to the most relevant authority or rule in making decisions.
• Consequentialism or utilitarianism: The act is chosen based on what one predicts will cause the greatest good for the most people.
• Something is good if applicable.
• Act utilitarianism focuses on the result and evaluates each circumstance on its own merits; no rule that always yields the greatest good exists to follow. 
• Rule utilitarianism focuses on means and makes decisions uniformly across circumstances; one chooses to follow a rule because that action will likely yield the greatest good over most iterations of a scenario.

Here are examples of rationales used by each of the above strategies, using the example of hand washing before doing a physical examination.

• Egoism: Cleanse one's hands as it maximizes the benefits for oneself.
• Altruism: Wash because it will contribute to the well-being of the individuals served.
• Cultural relativism: Wash because societal norms dictate such expectations. 
• Subjective relativism: Wash because the person believes washing is a positive and beneficial action. 
• Virtue ethics: Cleanse because maintaining cleanliness signifies excellence.
• Deontological ethics: Wash because washing is the right thing to do regardless of the outcome.
• Act utilitarianism: Wash as it should hinder the transmission of infection, leading to the most significant benefit. 
• Rule utilitarianism: Washing is essential since adhering to the rule is expected to minimize the transmission of infections during all physical examinations, leading to optimal outcomes across diverse situations, even if it may not be the best in this specific scenario.

These theories can overlap. The last strategy, rule utilitarianism, combines deontology and act utilitarianism. Rule utilitarianism requires people to act out of a duty to obey a rule that someone created to serve the greatest good for the most people. Rule utilitarianism is the most common form of ethics used in any profession with an ethics code. In medical ethics in the late 20th century, however, a return to emphasizing virtue ethics occurred. By shifting from the language of “duties of physicians” in 1847 to “principles of medical ethics” in 1957, the AMA combined concepts from duty ethics, virtue ethics, and consequentialism, which could be termed rule virtuism (American Medical Association. Code of Ethics of the American Medical Association. American Medical Association; 1848), (American Medical Association. Code of Medical Ethics. American Medical Association; 1957). 

5. Objectivity in Ethics

Both ethics and science aspire toward objectivity as a shared goal. Similar to science, medical ethics can maintain objectivity to a certain extent. Those who resist adopting a systematic approach to ethics, under the belief that ethics lacks objectivity, should bear in mind that even scientists conducting laboratory experiments encounter limitations to objectivity. For instance:

• The process by which a scientist formulates and conducts an experiment is inherently subjective and subject to variability.
• Employing the scientific method to investigate a matter frequently fails to establish a clear cause-and-effect relationship. 
• Applying the scientific method may not conclusively demonstrate the superiority of one theory or course of action over another.
• The interpretation and application of facts by scientists can vary.
• Scientists often draw conclusions that run afoul of Hume's "is-ought" problem.

One way to achieve objectivity when making ethical decisions is by using scientific principles, such as verifying what is or is not valid. Objective ethics or ethical absolutism, distinct from objectivist ethics or ethical objectivism, attempts to create a set of ethical rules that almost always hold. For an ethical behavior to be truly objective, it must depend on neither values nor beliefs but entirely on logic and observably true statements. Empirically demonstrating observable factual statements is possible, similar to how the concept in the sentence "the sun is larger than the earth" can be substantiated.

Some hypotheses and patterns in ethics can be studied using the scientific method. After randomly exposing a person to 1 or more independent variables, one can assess the dependent variable of their ethical stance or decision. Using the same techniques employed for measuring other variables, scientists can quantify and validate a person's beliefs and behaviors to some extent psychometrically.

On the 1 hand, ethics does not reach the level of some universal scientific laws because ethical principles cannot condense into proofs that demonstrate a specific action to be good in every situation. On the other hand, there do exist some actions that have no ethical justification, including forms of torture or retaliation like murder. (Aristotle. Nicomachean Ethics. 1.1094b, 2.61106a, 6.11138b18-34). The existence of some actions that lack merit by any system of logic demonstrates that some facets of ethics, like some scientific laws, can transcend location and time. 

A second way of obtaining objectivity is by removing perspectives that introduce bias. In medical ethics, a person can remove bias by:

• Addressing the issue at hand as if the decision must be made only by having the motivation to serve the good of the patient primarily affected by the decision. The decision-maker shall have no self-interest in the outcome or be blind to the actual outcome of the decision. 
• Addressing the issue as if the decision-maker were the patient and would experience the primary outcome of the decision.

A third approach to achieving objectivity involves consistently applying a standard across various circumstances. The individual employing this form of objectivity establishes a marker or point of reference to serve as an objective standard. An illustrative example from science is the definition of a single unit of temperature in the Celsius scale, where the temperature is the difference between the temperature of freezing and boiling water at sea level divided into 100 equal parts.

Once a standard is selected, a specific behavior could be assessed as right or wrong based on that predetermined standard in nearly any situation, regardless of the consequences of the behavior. Consequently, it becomes an obligation to perform or refrain from specific actions almost universally. The person utilizing this type of objectivity should do so in a manner that ensures the chosen standard is applicable or potentially applicable to numerous circumstances and individuals across various time points or instances. This approach is comparable to a mathematical algorithm designed to increase the likelihood of achieving the desired outcome over numerous instances, even if it means potentially sacrificing the desired outcome for a specific instance. This rule-utilitarian perspective stands in contrast to applying a decision solely to 1 or a few circumstances, individuals, or over a limited number of time points or instances.

Application of Medical Ethics 

To help navigate and understand the ethical standards of healthcare professionals, clinicians must understand the following:

• What the study of ethics involves
• How or why ethics change over time
• How to select an ethical authority
• How to identify bias and use perspectives in ethics
• How to maximize objectivity in ethics

Heuristics for marrying out medical ethics decisions

Philosophers Tom Beauchamp (1939-) and James Childress (1940-) introduced a transitional approach to medical ethics, providing simple heuristics emphasizing 4 principles based on a culmination of philosophies throughout time (Beauchamp T, Childress J. Principles of Medical Ethics. Oxford University Press; 1979).

Relying on these 4 principles allows healthcare professionals to make ethical decisions more quickly. Evolving from the AMA's 1957 word preferences, the chosen principles are:

• Beneficence: Advocate for the course of action that aligns with the patient's best interests. In other words, show altruism toward the patient. 
• Nonmaleficence: Do not harm the patient.
• Distributive justice: Apply equal or equitable treatment when handling matters involving more than 1 patient.
• Autonomy: Preserve patients' ability to make decisions independently of external control.

This heuristic is the dominant heuristic used by ethics code-writing organizations. The 2019 ACP's ethics code includes Beauchamp and Childress's 4 principles by name.[6] The 2017 AMA code defended all 4 principles in particular circumstances without explicitly using the word "nonmaleficence" or the word "distributive" before the word justice. By putting these principles, which are, in fact, virtues, into ethics codes, the AMA and other bodies have combined the concepts of virtue ethics, duty ethics, and act utilitarianism for beneficence, nonmaleficence, and autonomy and virtue ethics and rule utilitarianism for distributive justice. 

In another heuristic, Albert Jonsen (1931-2020), Mark Siegler (1941-), and William Winslade (1941-) focus on inputs rather than processes or outcomes intrinsic to every clinical encounter as a way to organize pertinent facts for a particular case (Jonsen A, Siegler M, Winslade W. Clinical Ethics. MacMillan; 1982). 

• Medical indications: Diagnosis, prognosis, treatment options, and physical treatment goals
• Patient preferences: Including the values that justify those preferences
• Patient quality of life: As experienced and determined by the patient
• Contextual features: Policy-based, financial, and social issues

Although Beauchamp and Childress' criteria have become the dominant heuristic used by ethics code-writing organizations, not all ethicists accept these criteria. As an example, Bernard Gert (1934-2011), Charles Culver (1934-2015), and Danner Clouser (1930-2000) made many similar conclusions but criticized some perspectives of Beauchamp and Childress (Gert B, Culver C, Clouser KD. Bioethics: A Return to Fundamentals. Oxford University Press; 1997). Their heuristic is the "ten duties," not the principles of healthcare providers:

• Do not kill someone.
• Do not cause pain for someone.
• Do not disable someone.
• Do not deprive someone of freedom.
• Do not deprive someone of pleasure.
• Do not deceive someone.
• Keep your promises to someone.
• Do not cheat someone.
• Obey the law.
• Do your duty.

A significant limitation of any compilation of ethical directives is the occurrence of situations in which conflict arises between any 2 ethical principles or duties. In medical practice, conflicts between principles and duties are not the exception but the norm. Healthcare professionals must choose which principle or duty takes precedence, acting as the ultimate goal. Selecting a primary ethics principle or duty influences the application of all other principles and decisions. Numerous medical ethics texts delve into these conflicts for specific clinical scenarios, particularly those involving conflicts between:

• Autonomy and beneficence
• Distributive justice and beneficence
• The "lesser of 2 evils" application of non-maleficence.

In the next section, we examine a much less commonly addressed but prevalent and significant conflict: beneficence vs. non-maleficence. 

Three Analyses of the Priority of Beneficence vs. Non-Maleficence in Healthcare

Analysis 1: Passages in medical texts and Abrahamic religious texts

Medical beneficence includes actively preventing harm and restoring health, even at the risk of causing harm. Without beneficence, the practice of medicine does not exist. Beneficence drives the activity of medicine itself. Non-maleficence restricts the activity. In other words, beneficence is the car or game, and non-maleficence is the boundary lines for the car or game.

Given that line of reasoning, it should be no surprise that in the Great Conversation, regarding medical ethics, the concept "first do no harm" is a relatively late entry. American physician Elisha Bartlett (1804-1855), who studied medicine in Paris, says that French pathologist Auguste Francois Chomel (1788-1858) invented that saying (Hooker W. Physician and Patient. Baker and Scribner; 1847. 219). The Hippocratic Oath and other ancient medical texts prescribed doing good before avoiding harm. The Hippocratic Oath's statement, "I will use treatment to help the sick according to my ability and judgment," precedes the oath's discussion on avoiding harm. 

The current AMA code's opening line states:" 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"(American Medical Association Council on Ethical and Judicial Affairs. AMA Code of Medical Ethics. American Medical Association; 2017).

The AMA text declines to state by what authority this moral imperative derives but, like the Hippocratic Oath, emphasizes putting patients' health above the physicians' needs and places non-maleficence as second to beneficence. "Do no harm" is not mentioned until Section 1.1.7. The authors of Chapter 1 do not develop the idea or application of non-maleficence to the same degree as they do beneficence. 

Since the AMA declined to do so, we turn to a brief discussion on moral authority. Gert 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. Gert also argues that non-maleficence is morally obligatory but that beneficence of any kind is not (Gert B. Common Morality. Oxford University Press; 2004). Gert argues that one cannot defend beneficence as a moral obligation. However, evidence exists for beneficence being a moral duty in some ancient religious texts like the Parable of the Good Samaritan (Luke 10:29–37), which states, "Go and do likewise." Religious debates often revolve around whether one should perform goodness or refrain from badness to determine which is more pious.

Christian scriptures address the issue most explicitly of Christian, Jewish, and Muslim sacred writings. Three different accounts of the words of Jesus of Nazareth on this matter exist. Two refer to a "greatest commandment," and the third refers to "what must be done to inherit eternal life" (Luke 2 and 10),(Mark 12),(Matthew 22 and 26). In 1 of these accounts, scholars report Jesus directly quoted Deuteronomy, saying that the greatest commandment is to acknowledge only 1 God as having dominion, which also is the mainstream religious interpretation of what the greatest commandment is in the entire Tanakh and Qu'ran, respectively (Deuteronomy 6),(Qu'ran Surahs 3, 20, and 47).

  In all 3 of Jesus' accounts, Jesus says that more than acknowledging a single God, the commandment states to love that God, and the second most important commandment is to love one's "neighbor." Thus, these 3 accounts imply that being good to others is more significant than simply refraining from maleficence and is an obligatory duty. This implication requires the assumption that loving involves being good and not just avoiding harm. Hadiths also tend to favor the priority of beneficence over non-maleficence (al-Bukhari M. (compiler). Sahih al-Bukhari. Chapter 2). 

Analysis 2: Society-level ethics and healthcare business ethics 

Businesspeople and governments have come to dominate and regulate the practice of medicine. Healthcare professionals face pressure to deviate from the ideals of "pure" medical ethics mentioned earlier and prioritize wealth accumulation for business managers while adhering to government-set policies and those of appointed agencies. Federal, state, and provincial legal codes in North America widely support the notion that uncompensated beneficence is commendable but not obligatory. Many clinicians believe their sole obligation is to make minimal efforts to prevent harm without necessarily attempting to relieve suffering. This behavior or perspective manifests more prominently as healthcare professionals transition from their early altruistic motivations for entering healthcare prioritizing financial gain and leisure later. Those in authoritative positions, whether businesspeople or healthcare professionals, within a healthcare organization may obstruct other clinicians from carrying out the altruism that initially inspired them to work in healthcare.

Social contract theory remains an integral part of medical ethics and law.[7][8][9] In social ethics or ethics about a whole society, Plato and later Hobbes describe the essential function of social contracts as avoiding harm (Plato. Republic. Book 2),(Hobbes, T. Leviathan. 1651: Part 2. chapters 17-31). However, Jean Jacques Rousseau's (1712-1778) version of social contract theory, based on the legal and medical ethics principle of patient autonomy, flipped it into a doctrine emphasizing doing good (Rousseau J. The Social Contract: or Principles of Political Right. 1762: Book 1; chapter 5).

Philosopher and political economist Adam Smith (1723-1790) continues to influence Western business ethics greatly, as supported by the many healthcare business, ethics, and economics articles that continue to reference him.[10][11][12][13] Smith argues that the well-being of strangers in a society depends on their cooperation but that it is nonsensical to expect businesspeople to show benevolence to strangers for altruistic reasons. Self-serving behaviors in business can sometimes help the larger society's economic situation (Smith A. An Inquiry into the Nature and Causes of the Wealth of Nations. 1776: Book 1; chapter 2).

Even though Smith made other clarifying statements, many subsequent writers have cherry-picked assertions and other claims to "excuse" businesspeople from complying with general ethics, resulting in a general loss of altruism in business ethics after the Enlightenment. 

In the 20th century, Western philosophers and judges began to apply updated versions of social contract theory to both the ethical and legal obligations of the medical and non-medical business professions. Demonstrating the "ethics-policy cycle" starting in the late 20th century and becoming more prevalent in the 21st century, businesspeople in both healthcare and non-healthcare organizations have experienced increasing pressure from customers and governments to act according to principles of "corporate social responsibility."[14][15] ( Please refer to the Evolution and Cycles of Ethics earlier in this section for additional information regarding the ethics-policy cycle). This pressure has occurred in Western and Eastern cultures, the latter of which did not lose the notion of social responsibility to the same degree as Western society. Interested readers can find many contemporary arguments that "charity" and "social responsibility," both forms of beneficence, are usually good for a business's financial gain and influence in its community long-term (Nickels W, McHugh J, McHugh S. Understanding Business. 11th ed. McGraw-Hill; 2015),(McElhaney K. Just Good Business: The Strategic Guide to Aligning Corporate Responsibility and Brand. Berrett-Koehler Publishers; 2008). Limited research exists on this issue in the healthcare business arena. Bartlett reviewed cost-benefit analyses of patient education techniques in various settings and concluded that specific patient education techniques result in cost savings on a systems level.[16] However, some clinicians do not educate patients or perform other beneficent acts due to the lack of direct financial reward.

Analysis 3: Relationship with 'excellence' and 'love' in ancient Greek philosophy

Certain professions in Western society, such as medicine, the military, and the police, can trace their governing principles to an ancient Greek commitment αρετη or excellence, where something is excellent if it functions well for oneself or one's society (Aristotle. Nicomachean Ethics. 1.1094b, 2.61106a, 6.11138b18-34), (Paul of Tarsus. Epistle to the Philippians. Chapter 4). In modern language, to excel means to go beyond the average, let alone the minimum (Merriam-Webster. 2023. "Excel." https://www.merriam-webster.com/dictionary/excel. Accessed November 3, 2023).

The foremost duty of soldiers may be to protect their fellow soldiers or succeed in a mission or die trying. The foremost duty of police officers may be "to serve and protect" citizens of their jurisdiction. The foremost duty of healthcare professionals is to protect their patients' health through a fiduciary relationship.[17] A fiduciary relationship involves not simply "keeping from harm" but includes "promoting the patient's best interests." Persons who enter these 3 mentioned professions often feel a call to serve others based on their religious or non-religious moral convictions, compelling them to serve beyond meeting a minimum standard set by a business manager or a judge. Gert was married to his childhood sweetheart for over 50 years before being separated by death. Achieving such a union demands some form of excellence, even though fulfilling a defined minimum duty is possible. For those engaged in such a relationship, its significance often stems from another fundamental aspect of humanity, which can also serve as the motivating factor for a healthcare professional's conduct toward patients: love expressed in Greek as αγαπη, the same term used in books of Matthew, Mark, and Luke, in the Bible and the Greek translation of Deuteronomy as the second-highest moral commandment.

Proposed Formula for Beneficence and a Hierarchy of Beneficence, Autonomy, Non-Maleficence, and Distributive Justice in Medical Practice.

Based on the above analysis, we conclude that beneficence takes precedence over non-maleficence in medical ethics. In other words, "First, do good." Whether in law, philosophy, business, or medicine, controversy exists when defending the degree to which beneficence is required. We propose an objective formula for when some attempt at beneficence is necessary. The formula considers costs to the person or group of people analyzing how or whether to act, referred to as a risk (R) of significant loss or damage.

A person or group of people (P) must perform an act of beneficence (aB) to some other person (Op) in the following situations:

• The Op risks significant loss or damage (R) to some fundamental interest.
• The aB is definitely or likely necessary to prevent R.
• The aB does not present a significant R to P.

In other words, a beneficent act by you is obligatory when the act's expected ability to promote health to a patient outweighs the risk of it causing similar harm to you.

Gert himself agreed that administrators of healthcare organizations should optimize physicians' time spent for beneficence while still meeting business expectations and policy requirements by utilizing advanced practice providers or assistants to reduce physician time spent on tasks not required for a physician to accomplish, like patient education, data gathering, correspondence, and procedure organization (Gert B. Bioethics: A Systematic Approach. 2nd ed. Oxford University Press; 2006). Gert asserted that a person cannot impartially distribute equal or unlimited goodness to all persons at all times, supporting limited distributive justice, where each patient receives only a small amount of good. Medical ethicists typically discuss the conflict only in the context of emergencies, where time or other resources are minimal. It would be helpful for clinicians to have more guidance on resolving this tension between distributive justice and beneficence, but such a discussion is beyond the scope of this article.

Instead, we summarize by proposing the following hierarchy of Beauchamp and Chldriess' 4 principles of medical ethics:

Non-Emergency setting

1. The clinician should proceed with what they deem beneficial for the patient, given the patient's agreement that no superior option exists- an example of beneficence and respect for autonomy. 
2. If the patient disagrees that the clinician's plan is the best option, then the clinician stops, which respects the patient's autonomy.
3. If the clinician considers acting in a way they know could harm the patient, they should stop- an example of non-maleficence. The exception is if the intent of the action that could harm the patient is the least threatening or the most desirable means to an end available, and the patient agrees with the action after providing informed consent- an example of beneficence and respect for autonomy. Only proceed if meeting these 3 conditions.

Emergency setting

Practice distributive justice by rationing beneficence evenly and equitably among patients. Otherwise, proceed as for non-emergency settings.

Although successfully performing each of these tasks to the satisfaction of every patient is impossible, the AMA code directs physicians to make a good-faith attempt.  

Clinical Significance

Ethics and medicine function as complementary approaches for enhancing human life. A student of the medical sciences cannot attain mastery in medicine if they can only identify the proper treatment based on instructions from others and cannot reference any other standard. Similarly, comprehending the rationale behind using a specific standard to discern the proper basis for decision-making is necessary to achieve mastery in ethics. Healthcare professionals and others engaged in the healthcare industry must prioritize ethical principles.

Medical ethics undergoes intertwined developments with other ethical fields, experiencing relatively rapid changes, often occurring within a single lifetime. Utilizing a system of ethical principles with varying hierarchies is a relatively recent phenomenon within the last 50 years. The inaugural code of medical ethics emerged after the advent of the antiseptic technique and stethoscope, coinciding with the invention of general anesthetics. A pivotal moment in the direct involvement of the United States government in medical ethics occurred in 1966 with Henry Beecher's reports.[17] 

In response to Beauchamp and Childress in 1980, the AMA streamlined its code from the original 4 chapters spanning 20 pages to 7 minimally elaborated principles (American Medical Association. Code of Medical Ethics. American Medical Association; 1980). By then, state legislatures and hospitals had taken over doctors' political agendas, initially a significant part of the AMA's motivation for an ethics code in the 1840s. The impact of ethicists' reactions to the civil rights movement of the 1960s and 1970s and the medical technology revolution of the latter half of the 20th century had yet to manifest fully at the level of the AMA. In 1998, commemorating the 150th anniversary of the original code, the AMA expanded the code to 9 chapters spanning more than 150 pages (American Medical Association. AMA Code of Ethics. American Medical Association; 1997). Subsequently, the AMA expanded the code to 11 chapters, covering over 200 pages (American Medical Association Council on Ethical and Judicial Affairs. AMA Code of Medical Ethics. American Medical Association; 2017).

Article IV of the 1980 AMA Code added the language of patient rights: "A physician shall respect the rights of patients, colleagues, and other health professionals," with the 2017 code expanding patient rights to an entire page (American Medical Association. Code of Medical Ethics. American Medical Association; 1980),(American Medical Association Council on Ethical and Judicial Affairs. AMA Code of Medical Ethics. American Medical Association; 2017). Patient rights are related to medical ethics but also involve additional ethical considerations and legal factors discussed elsewhere.[17] 

Medical ethics authorship and scope continue to expand. By 2017, 12 journals devoted to medical ethics and indexed in PubMed reached a citation index factor 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 regarding ethics and the following topics:

• Use of medical technology[18]
• Medical treatment of populations[19]
• Human reproduction[20]
• Mental health[21]
• Organ donation[22]
• Surrogate decision making[23]
• Suicide and assisted death[24]
• Limits in the extent of services of critical care medicine[25] 
• Clinical trials[26]

Other Issues

Medical ethics intertwine with morality and are not a purely secular endeavor for many healthcare professionals and patients. This discussion involves the issue of ethics versus morality and their status in modern medicine in the United States, returning to the issue of authority in ethics.

Neglecting the influence of beliefs about God on establishing the principles of medical ethics is historically inaccurate and incomplete. Since ancient times, predating 2000 BCE, the prevailing religion of the state has shaped writings on medical ethics.[Morenz] It was in the mid-1700s CE that approaches to normative ethics, including medical ethics, began to assert independence from theology. In other words, only in the last 5% to 10% of history have mainstream philosophers, like Kant and Hume, detached divine rules and covenants from ethics, relegating them to the realm of morality. Healthcare ethicists waited even longer. The chairperson of the 1847 AMA code committee, physician John Bell (1796-1872), asserted that "medical ethics, as a branch of general ethics, must rest on the basis of religion..."[AMA 1948] George Wood (1797-1879), AMA president in 1853, recommended 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."[Wood]

In 2017, over 70% of Americans identified as belonging to an Abrahamic religion of Christianity, Islam, or Judaism (Cox D, Jones RP. America’s Changing Religious Identity, 2016 American Values Atlas. Public Religion Research Institute; 9 June 2017). Approximately 2% identified as belonging to 1 of the other 2 most prominent world religions, Hinduism or Buddhism, and approximately 6% identified as atheist or agnostic. At least 20% of American hospital beds remain in religion-affiliated hospitals (Kaye J, Amiri B Melling L, Dalven J. Health Care Denied. American Civil Liberties Union; 2016).

The prevailing practice in the United States involves enforcing moral principles and distinguishing between right and wrong by secular entities such as governments, government-appointed bodies, professional societies, and businesses. Nevertheless, healthcare professionals and the patients and family members they encounter often attribute the highest ethical authority to texts they believe contain directives from God. Disregarding concepts from theology and theodicy when applying modern medical ethics codes to patients and other healthcare professionals for whom these concepts hold significance is an uninformed and potentially harmful application of ethics.

Enhancing Healthcare Team Outcomes

Patient care involves many collaborating healthcare professionals. This collaborative approach provides coordinated, cost-effective, and high-quality health care. Healthcare teams involve physicians, advanced practice practitioners, nurses, pharmacists, therapists, social workers, and other clinicians, with each member having various clinical and administrative roles. Familiarity with ethical principles is essential to provide comprehensive, patient-centered care.

Medical ethics codes emphasize that the duty of healthcare professionals to the patient's well-being takes precedence over their duties to all others and extends beyond mere harm prevention. However, these codes often fail to address common real-world conflicts in ethical behaviors toward patients and non-patients. They often lack explanations for conflicting forces. Conflicts may arise when adhering to ethical principles concerning patient care, which may cause tension with other healthcare professionals, business administrators, risk managers, trainees, or other individuals involved in a patient's care.

Due to the absence of universally applicable ethical standards and premises for all healthcare professionals, healthcare teams frequently grapple with finding solutions to ethical challenges that satisfy all parties involved. Collaborating as an interprofessional team, with each member trained in medical ethics, ensures that ethical considerations guide decision-making. This collaborative approach promotes patient-centered care, informed consent, and patient autonomy in treatment choices. Additional sources on the ethics of teams, including healthcare teams, are available for readers interested in exploring this topic further, though they are beyond the scope of this article.[27]