Medical ethics can be very complex, and often the decisions made resolving ethical dilemmas have dramatic consequences. The decisions resolving business ethical issues often result in financial consequences, but in medical ethics the decisions made involve life and death issues. Ethics very often is about resolving conflicts of legitimate values, or "right versus right." Medical ethics most of the time is about "wrong versus wrong." It is almost never possible to find the perfect solution but rather to be content with finding the least harmful one.
One of the basic tenets of medical ethics is a fundamental respect for life and for the individual in all aspects. Medical ethics is based on the principles of the best interests of the patient, including dignity, honesty, the patient's right to refuse or choose treatment, and fairness in the distribution of limited health resources. Most importantly, it is based on the obligation to cause no harm, or at least to cause the least possible harm.
Most scholars believe that the first document addressing medical ethics is the Hippocratic Oath, written in the fourth century B.C.E. by Hippocrates, the father of medicine. We know very little about him except that he was a physician and a professor of medicine and that he lived on the Greek island of Kos. The Hippocratic Oath (see sidebar, pg. 32) addressed the issues of confidentiality, abortion, and prescription of a drug that could cause death. Most importantly, the oath insists on the concept of "causing no harm."
Nearly all medical institutions today have replaced the Hippocratic Oath with a more modern version. One such version is the Oath of Maimonides (side bar, pg. 32).
Today, medical students in the U.S. are not obligated to take any oath, but if they are a member of the American Medical Association they must uphold its nine Principles of Medical Ethics.
Principles and codes are helpful guidelines in resolving medical issues. Medical Ethics Committees can also be helpful. Today, most hospitals in the U.S. have such committees but they only serve in an advisory capacity to physicians and do not make the ultimate decisions.
New discoveries and scientific progress in the medical fields pose complex moral dilemmas. It is always difficult to draw a line between what is acceptable and what is not when entering uncharted territories. This has always been the case. In its preamble the AMA recognizes that: "Changes in society, science and the law constantly raise new ethical issues and may challenge existing ethical perspectives." Scientific advancement has always provoked new challenges for the ethicist, and ultimately for the legislator. Organ transplantation, when first introduced, was vehemently opposed by many groups, including the Catholic Church. It was considered a mutilation of the body. It is now broadly accepted and practiced.
One of the reasons progress is often opposed is the basic human fear that has accompanied new discoveries. This is particularly true in medicine. These fears are sometimes very well justified. We have witnessed catastrophic results when no moral restraints are imposed on scientific research and discoveries. Joseph Mengele was a Nazi physician! Yet he used men, women and children as the subjects of his depraved medical research, presumably for the benefit of mankind or, more precisely, for the benefit of the Aryan race. Scientific research on syphilis, the "Tuskegee syphilis experiment," was conducted in Alabama from 1932 to 1972 in which black males were left untreated for the benefit of "the experiment," as opposed to the benefit of the individual.
There is no doubt that cloning research will lead to the cure of genetic diseases. However cloning also represents dangers. There are medical, ethical and social implications in cloning. One of the issues is the safety of the procedure as well as its reliability. There are other important issues to resolve, such as: Would an individual created by cloning, whose genes are predicted and determined, be a human being in the full sense of the word, free to choose his or her future? Would society treat these cloned human beings like all other humans?
There is also the danger that in cloning we are "playing God" by creating human beings to our image of perfection, both genetically and esthetically. The fantasy of creating a "perfect race" was enacted in Nazi Germany with the Lebensborn program, created by Heinrich Himmler in 1935. The goal of the program was to create a "super race" by offering young girls deemed to be "racially pure" to mate, in secret, with SS men in order to give birth to an Aryan generation. The children born by this state-ordained rape were taken away from their mothers and given to SS organizations, who took charge of their "education."
Stem Cell Research
Another issue that is much debated today is stem cell research, which could have promising results in curing diseases such as Alzheimer's and Diabetes. Recently, The Journal of American Medical Association published the results of a study conducted by Brazil University and Northwestern University, which found that transplanted stem cells taken from bone marrow could free diabetics from the need to use insulin for long periods of time. Some ardently oppose it on the basis that any embryo, even in its early stage, is a human being and therefore its destruction is equivalent to murder. What we may forget is that the debate is only about public funding. The current government policies allow the private sector to conduct such research. There is a legitimate concern about the absence of government supervision as well as the potential conflicts of interest for scientists between financial rewards and the well being of the participants. Harold Shapiro, former president of Princeton University and former head of the national Bioethics Advisory Commission, believes that every participant in medical research should be covered by two principles: "An independent review and voluntary consent based on respect of the autonomy and right of the individual participant." Laurie Zolith, co-author of The Embryonic Stem Cells Debate, Science, Ethics and Public Policy believes that Jewish ethicists generally justify cell research because they believe that the human embryo does not have the status of a human person and because there is a commandment to heal. Furthermore, they believe that the world is incomplete and requires human participation to become whole.
Religious beliefs have strongly influenced medical ethics.
Rabbi Jonathan Sacks, current Chief Rabbi of the British Commonwealth, said: "In terms of ethics, Judaism was the first religion to insist upon the dignity of the person and the sanctity of human life. For the first time, the individual could no longer be sacrificed for the group. Murder became not just a crime against man but a sin against God." However, as Judeo-Christian influence erodes in Western society, traditional ethical norms are giving way to the only remaining absolute: maximizing happiness. But doesn't sacrificing one to benefit all make all vulnerable?
Religious belief can also be in conflict with current medical ethics. A recent study conducted at the University of Chicago found that 14% of physicians believed that it was acceptable to withhold information and therapeutic options from patients if they disagreed for moral reasons on the therapies available. Dr. David Magnus, Director of Stanford University's Center for Biomedical Ethics, in response to the survey said: "There are a lot of physicians out there who are not, in fact, doing the right thing." The American Medical Association does not require doctors to provide a treatment to a patient if that treatment is contrary to their moral beliefs. According to a study published by The New England
Journal of Medicine, 63% of the 2,000 physicians surveyed believed that it would be ethical for them to "plainly" explain their moral objections to their patients.
A new vaccine has recently been developed against cervical cancer. Some are proposing a universal vaccination program that could saves the lives of thousands of women if administered before puberty. The vaccination would be performed through the school system. Cervical cancer strikes more than 10,000 women a year and kills more than 3,700. The vaccine also protects women from some STDs. Religious groups who fear that it could send the wrong message to young people by promoting promiscuity oppose the vaccination program. Gene Rudd, associate executive director of the Christian Medical and Dental Associations, said: "Parents should have the choice. There are those who would say, we can provide a better, healthier alternative than the vaccine, and that is to teach abstinence."
Dr. Everet Koop, the former Surgeon General, himself a man of strong faith, surprised his Christian friends when he advocated the distribution of condoms. His argument for doing so was that, as a physician, his first priority was to save lives, even if, indirectly, it might encouraged the practice a life style that he disapproved.
The Catholic Church and some Protestant groups oppose abortion on the premise that life begins at conception and therefore, abortion is murder. They believe that the commandment "Thou Shall Not Kill" applies in this case. In Judaism, according to Daniel Eisenberg, from the Einstein Medical Center, the traditional Jewish view of abortion does not fit conveniently into any of the major camps in the current debate over abortion. Jewish law does not ban abortion completely, neither does it allow indiscriminate abortion. Abortion is permitted only when there is a direct threat to the life of the mother. Judaism recognizes psychological and psychiatric factors in evaluating the potential threat to the mother's life.
The Jehovah's Witnesses oppose blood transfusion, based on the Scripture that "Life is in the Blood." Not too long ago, a mother and her 16-year-old son were both brought to the hospital in a comas, victims of a car accident. The husband and a daughter were in the car behind them and were not hurt. The mother and son needed an urgent blood transfusion or they would both die. However, the husband told the physician that they were members of the Jehovah's Witnesses believe that a blood transfusion is a sin that will condemn both victims to eternal damnation. They categorically refused to allow the hospital to proceed with the transfusion. What should the physician have done? Does a father and husband have the moral right to refuse life-saving treatment for his wife and child? The physician could assume but not be certain that if the mother were conscious, she would refuse the treatment. Religious beliefs can falter when faced with imminent death. What about the teenager? It is impossible to know if he would be just going along with his family's religion or whether he would be ready to die for his beliefs. Even if he did the latter, did he have the maturity to make such a decision?
Holland is the only country in the world where euthanasia is openly practiced. However, the practice is authorized under very strict conditions. According to the Royal Dutch Medical Association, the requirements are:
- That the patient makes a voluntary request.
- That the request is well considered.
- That the patient's wish to die has been expressed more than once and for a certain period of time.
- That the patient be in unbearable suffering.
- That the physician has consulted with a colleague who agrees with the proposed action.
In the U.S, most states have laws that specifically prohibit assisted suicide. In those states that do not have specific laws, assisted suicide is prohibited under the general homicide laws. Oregon is the only state that passed a law that specifically authorizes physicianassisted suicide.
However, in the U.S. giving pain relief to a patient that may shorten his or her life is not considered euthanasia but a normal medical decision in terminal care.
Jack Kevorkian, the "Death Doctor," assisted in the suicide of nearly one hundred terminally ill patients between 1990 and 1998. He claims that in each of these cases, the individuals themselves took the final action. He was convicted in 1999 of seconddegree homicide, having served 8 years in prison. He was recently released on the condition that he never again counsel a terminally ill person on how to die. However he remains a passionate advocate of assisted suicide.
Some believe that there is no moral difference between killing and allowing to die. Richard Gula, Ph.D., professor of moral theology at the St. Patrick Seminary in Menlo Park, California, argues that the concept of the sanctity of life obligates us to nurture and support life and also compels us not to cause harm. He also warns of the danger to not value life based in some arbitrary concept of its usefulness.
The proponents of euthanasia argue that it is ultimately an issue of civil liberty. Derek Humphrey, author of Exit and founder of the Hemlock Society, says, "If we cannot go to our death in the manner of our own choosing, what liberty do we have?" He believes that granting the wish to die to terminally ill, mentally competent adults in unbearable pain is really an act of love.
One of the fundamental issues in medical ethics is determining who should be making the decisions when the patient for one reason or another is unable to. Should it be the family, the physician, the hospital or the insurance companies? What about the theologian and the philosopher? Should they be brought into the decision-making process?
Leaving the burden of the decision solely to the family can be extremely painful and dramatic. And what if family members do not agree? Such was the case with the Terri Shiavo drama. She had been in a comatose state for a number of years and was on life support. Her husband was categorical in saying that his wife, in prior years, had specifically expressed her will not to be on life support should anything happen to her. Terry's father and mother insisted on keeping her alive. The case went all the way to the Supreme Court, which ruled in favor of the husband's position. Terri was taken off life support and died. To avoid such dilemmas, many advocate a living will in which an individual clearly spells out his or her wishes in case of incapacity. Margaret R. McLean, director of healthcare and biotechnology ethics at the Markkula Center for Applied Ethics, says that, "The moral bedrock of our decision-making about death is autonomy, our ability to decide for ourselves and to have people honor our choices." The problem, of course, is when we lose our autonomy and the capacity to make a decision. Who should make the decision then?
There is a tendency today to rely primarily on physicians to make the ultimate decision. Physicians are human and they make mistakes. In his recent book How Doctors Think, Jerome Groopman says that 15% of patients receive inaccurate diagnoses. This percentage matches other findings based on autopsies. Physicians are also primarily scientists, but the questions faced are essentially moral. Bioethicist Dr. Moses Tendler says that, "By default, society has assigned the physician the role of theologian and moralist a role for which he has no competence. The fear of sickness and death, added by the intentionally cultivated aura of mystery and the deep respect of the laity for scientific achievement, has resulted in this unwritten election of the medical community as arbiter of the most fundamental truths of Torah morality and of Western Civilization."
George D. Hanzel, M.D. chairman of the Institutional Ethics Committees at the Lee University Hospital, believes that "Everything that we do has ethical implications. That does not mean, however, that all physicians know how to think ethically. Probably 90-95 percent of the 'ethical issues' with which a physician is presented he or she can solve them out of his or her own intuitive ethical nature. There's that five or ten percent that is a little more thorny that need help from the discipline of medical ethics. When an ethical dilemma occurs, it's not so much a question of, "'Shall I do the right thing or the wrong thing,' it's, 'Which good that I'm trying to achieve is the better good?'"
Individual Versus Community
Some issues in medical ethics have to deal with knowing when the good of society should supercede the good of the individual. Dr. Daniel Eisenberg, in the Department of Radiology at the Albert Einstein Medical Center in Philadelphia, PA, and an Assistant Professor at Thomas Jefferson University School of Medicine, claims that our most egregious medical ethical lapse of the twentieth century can be traced to the concept that the needs of society supercede the needs of the individual. He says that: "When we look back at the past hundred years, we face the uncomfortable reality that the scientific community, and the medical community in particular, have been the impetus for some of the most barbaric and immoral programs of the 20th century. It becomes painfully apparent that secular, scientific and medical credentials do not imply moral rectitude. In fact, an immoral person with credentials is granted latitude that would not otherwise be bestowed upon the average person." Among the medical lapses he mentions is the United States's eugenic movement in the '20s and '30s that lead to the creation of the United State Eugenics Office, which promoted involuntary sterilization of individuals with "degenerate hereditary qualities." Mr. Harry Laughlin, superintendent of the U.S. Eugenics Office, proposed a list of those "degenerate qualities" that included: "the blind, including those with seriously impaired vision; deaf, including those with seriously impaired hearing; dependents, including orphans, ne'er-do-wells, the homeless, tramps, and paupers." More than 20,000 people were submitted to these forced sterilizations.
There will always be fewer limited resources for medical care than a society can provide. The demands will always be greater than the supply. Limited resources in healthcare can pose some serious ethical dilemmas. What are or what should be the criteria in deciding who gets help and who does not?
More than 46 millions Americans have no health insurance. Sadly, the people who need it the most because of limited financial resources are precisely those who are not insured. This seems to be a basic social injustice. Even if we adopted a Universal Healthcare system in the U.S. we still would have ethical issues of medical health distribution.
We have an acute shortage of available organs for transplantation, and therefore there are long waiting lists of patients who may very well die unless the operation is done rapidly. People with financial means may have an advantage, but is it fair? To prevent such injustice Congress passed the National Organ Transplant Act in 1984, which makes it a felony to give or receive something of value in exchange for an organ.
Today more than 70,000 people need a kidney and must, unless they have a friend or relative willing to donate, go on a national waiting list for a deceased donor organ. Only 25% of them will receive the transplant. The others have a 50% chance to survive on dialysis. This year, Congress passed the Norwood Living Organ Donation Act, also known as the "paired kidney donation" whereby incompatible donor-recipient pairs are coupled with other living incompatible donor-recipient pairs to achieve successful transplant matches. This new "swap" law will increase the number of transplants by 15 to 30%. Dr. Sally Satel, the resident scholar at the American Enterprise Institute, says that it is a good first step but not nearly enough to save the lives of thousands in need of transplants. She suggests allowing some form of compensation or incentives for potential donors, such as lifetime Medicare coverage, tax credits, and tuition vouchers for a donor's children. It is true that combining organ donation with financial compensation is not ideal, but if it can save the lives of thousands, we should consider it. "After all," she says, "no one objects to a tax credit for a charitable contribution."
Ethics and Managed Care
Patricia Illingworth, associate Professor, Department of Philosophy lecturer in law and at Northeastern University, believes that the fundamental change in the doctor-patient relationship affects the general level of trust available in our society.
She believes that trust is at the basis of the doctor-patient relationship and that our current Managed Care system threatens to compromise that relationship because of the role of third parties such as the employer and the insurance companies. These third parties may seriously impact the trust patients have in their physicians. It also lessens the responsibility of physicians, and that directly affects the most vulnerable patients.
The rising cost of healthcare also threatens the trust relationship between doctors and patients. The therapeutic decisions made by physicians may be strongly influenced by cost considerations, which may not necessarily be beneficial to the patient.
New Trends in Bioethics
Bioethics is evolving and is now embracing public health issues. There is a shift of concern from the individual to the collective. Issues of the consequences of tobacco and high-fat diets on populations are now a major concern of bioethicists.
There is also the effect of globalization. Medical ethics is now dealing with the shocking and unjust discrepancies in the level of healthcare available in different countries. Poverty is the cause of most of the world's health problems. Some African countries spend twice as much on repaying debt than they do on healthcare. Furthermore, we are more aware today that diseases such as AIDS and tuberculosis anywhere in the world directly impact our society.
It is difficult to consider the topic of medical ethics without first coming to an understanding of the definition of life. What is life, when does it begin and when does it end?
There are different points of view in answer to these questions, and therefore very different opinions on topics such as abortion, cloning and euthanasia. The point of view of a theologian might differ from the point of view of a physician. Similarly, a philosopher might have an approach that would be different from the approach of a sociologist.
The discussion and public debate on these issues are essential in our attempts to define our culture and our society. In ethics, the worst-case scenario is when no questions are asked. We need to question what we do, what our values are and, more importantly, we need to question ourselves.