Medical Ethics Overview

When we think about the Art and the Science of Medicine, the science is fairly straightforward to discern. We learn physiologic and pathophysiologic processes; diagnoses and treatments. We stay abreast of the literature and discoveries in our fields. The Art is somewhat more elusive. Some believe that it is inherent in anyone who wants to become a doctor. The selection process effectively chooses women and men who possess the right character. For others, especially in many large physicians groups for whom uniformity leads to predictable outcomes, the Art is scripted and deliberate. Physician-patient interactions are prescribed and physicians practice these interactions. The Art is more paint by numbers than it is a personalized original. Where ought one find the Art of Medicine? Is it on one end of the spectrum simply intuitive and inherent, or is there a formula, which if followed, will produce the Art?

At ProNobis Health, we believe that the Art of Medicine is practiced by cultivating the personal values and human character reflected in medicine’s ethical traditions. We believe that this takes place through deliberate reflection on our experiences as physicians. Along with a well developed intellect, physicians also need to have a well formed personal and professional morality. In this section, we give an overview of the importance of ethics in medical practice and research. One aspect of this is understanding the ethical theories that are often invoked in the practice of medicine. Another part is character development, cultivation of the personal values which are inherent in professional morality, particularly found in the Hippocratic Oath. Professional autonomy requires both judgment and accountability. Despite being well grounded in ethical theory and developing a mature moral character, physicians often find themselves in moral dilemmas.

What is wrong? What can be done? What should be done?

While knowledge of ethical theories can not substitute for thoughtful engagement of stakeholders in considering what to do in an ethically complex clinical situation, it can help us as physicians in thinking about what we should do. What we will describe are the common ethical theories used to consider ethical options. In treating a patient, physicians must ask three questions: What is wrong? What can be done? What should be done? Scientific and medical knowledge tells us what is wrong, and what can be done. Judgement, under the auspices of professional autonomy, guides us in answering “What should be done?”. Unless we understand the underlying medicine, we are not able to make the correct diagnosis or prescribe the right treatment. Similarly, understanding both general ethical theories and also those which have traditionally been applied specifically to medicine, we are better able to think about what we should do for a patient and if we should do it. Ethics and morals informs the answer to what should be done. By virtue of our training and the relationship we have with patients, physicians commit to action. We operate, prescribe, listen, talk, examine and intervene. Often we are more comfortable with answering what is wrong and what can be done, but we are often most troubled by what should be done. Should I insert a feeding tube into the stomach of a terminally ill patient? Should I administer CPR on this patient in a persistent vegetative state? Should I order an intraoperative transfusion to save this patient’s life, contrary to her wishes? By understanding the ethical foundations and integrating the values inherent in the ethical tradition of medicine, we find guidance in answering what should be done. We also develop our character, thus building the Art of medicine.

Historical Perspective – Nuremberg Code

At the end of World War II, the physicians who had participated in experiments on human beings were tried at Nuremberg as part of what is called “The Doctors’ Trial”. Beginning December 6, 1946 and ending July 19, 1947, the defense argued that there was that there was no agreed upon standard regulating experimentation on human beings. The defense further pointed out how similar the Nazi physicians’ experiments were to experiments conducted by physicians on humans in France, Britain, the Netherlands and the United States. Although the Hippocratic Oath was referenced by the prosecution as the ethical standard, it was recognized that the fundamental tenets of the Hippocratic Oath required interpretation as they applied to experimentation on human beings. This led to the formulation of the Nuremberg Code.

The importance here is the recognition that although the Hippocratic Oath is often cited as the ancient and authoritative ethical foundation on which medical ethics is established, it does require interpretation and application. Understanding bioethics involves not only studying the Hippocratic Oath, but also the ethical theories that seek to extract truths based on the Oath that can be applied to a variety of cases.

Ethics, Morals and Laws

In considering ethical theories or frameworks, an important distinction is between ethics, morals and laws. Ethics are general frameworks that seek to be broadly applicable in giving guidance about what a physician should do. As we will see, different frameworks have different starting points for answering the question of what should be done. Some ethical theories are general, such as natural law, and some are specific to medicine, such as the Hippocratic Oath. Ethical frameworks provide the basis for considering options and also the justification for determining that something is, or is not, an ethical option. Morals, on the other hand, are individual beliefs that are influenced by many factors including ethics, culture, personal values and religious beliefs. Morals judge whether an act is right or wrong, good or bad. They are not always universally applicable in the same way ethics try to be. Laws formulate a set of rules which govern the behavior of people in order to allow a society to function. Like ethics, laws should seek to be universally applicable.

In bioethics, there can be conflicts between ethics, morals and laws. Even on an individual level, a physician can believe that something such as physician assisted suicide is an ethical option for a terminally ill patient who is suffering, but the physician may not morally be willing to prescribe the medication for the patient. Further, depending on where one lives, although a physician may hold that assisted death is an ethical option for a terminally ill patient, and may be willing to assist, prescribing a lethal dose of a barbiturate may not be legal. There can also be conflicts between what physicians see as their ethical responsibility to preserve life and a patient’s moral beliefs about a potentially life saving treatment. A classic example is a Jehovah’s Witness refusing a life saving blood transfusion. When there is conflict, understanding ethical frameworks can be useful for determining what a physician should do.