-Historically, Western medical ethics may be traced to guidelines on the duty of physicians in antiquity, such as the Hippocratic Oath, and early rabbinic and Christian teachings. In the medieval and early modern period, the field is indebted to Muslim physicians such as Ishaq bin Ali Rahawi (who wrote the Conduct of a Physician, the first book dedicated to medical ethics) and al-Razi (known as Rhazes in the West), Jewish thinkers such as Maimonides, Roman Catholic scholastic thinkers such as Thomas Aquinas, and the case-oriented analysis (casuistry) of Catholic moral theology. These intellectual traditions continue in Catholic and Jewish medical ethics.
By the 18th and 19th centuries, medical ethics emerged as a more self-conscious discourse. For instance, authors such as the British Doctor Thomas Percival (1740-1804) of Manchester wrote about "medical jurisprudence" and reporte**y coined the phrase "medical ethics." Percival's guidelines related to physician consultations have been criticized as being excessively protective of the home physician's reputation. Jeffrey Berlant is one such critic who considers Percival's codes of physician consultations as being an early example of the anti competitive, "guild", like nature of the physician community. In 1847, the American Medical Association adopted its first code of ethics, with this being based in large part upon Percival's work . While the secularized field borrowed largely from Catholic medical ethics, in the 20th century a distinctively liberal Protestant approach was articulated by thinkers such as Joseph Fletcher. In the 1960's and 1970's, building upon liberal theory and procedural justice, much of the discourse of medical ethics went through a dramatic shift and largely reconfigured itself into bioethics.
Values in medical ethics
-Six of the values that commonly apply to medical ethics discussions are:
• Beneficence - a practitioner should act in the best interest of the patient.
• Non-maleficence - "first, do no harm"
• Autonomy - the patient has the right to refuse or choose their treatment.
• Justice - concerns the distribution of scarce health resources, and the decision of who gets what treatment (fairness and equality).
• Dignity - the patient (and the person treating the patient) have the right to dignity.
• Truthfulness and honesty - the concept of informed consent has increased in importance since the historical events of the Doctors' Trial of the Nuremberg trials and Tuskegee Syphilis Study.
Values such as these do not give answers as to how to han**e a particular situation, but provide a useful framework for understanding conflicts.
When moral values are in conflict, the result may be an ethical dilemma or crisis. Writers about medical ethics have suggested many methods to help resolve conflicts involving medical ethics. Sometimes, no good solution to a dilemma in medical ethics exists, and occasionally, the values of the medical community (i.e., the hospital and its staff) conflict with the values of the individual patient, family, or larger non-medical community. Conflicts can also arise between health care providers, or among family members. For example, the principles of autonomy and beneficence clash when patients refuse life-saving blood transfusion, and truth-telling was not emphasized to a large extent before the HIV era.
In the United Kingdom, General Medical Council provides clear modern guidance in the form of its 'Good Medical Practice' statement.
The case of Baby K.
-Despite being aware of the baby's condition prior to birth,(citation needed as to accuracy of diagnosis) Ms. H., the mother of Baby K., carried the child to term, in spite of medical advice to abort. Motivated by a strong religious conviction that "all life is precious" and that God alone should decide how long the baby would live, she remained adamant that Baby K. be kept alive as long as possible. The hospital’s position was that such care would be futile.
Ms. H. wanted the hospital to continue with advanced supportive care (primarily ventilatory support), despite the generally accepted medical practice that anencephaly is not curable or treatable, and that maintained life support would be both futile and wasteful. Fairfax Hospital doctors advised a Do Not Resuscitate condition for the child. The mother refused the DNR. Baby K. was left on ventilator support for 6 weeks while Fairfax searched for another hospital to transfer her to, but all area hospitals claimed they had no room (which is believed to be not entirely true; that in actuality no other hospital wanted to take over the futile medical care expectations and legal issues surrounding the child).
After the baby came off of constant ventilator support, Ms. H. agreed to move the child to a nursing facility, but the baby returned to the hospital many times for respiratory problems.
At 6 months old, Baby K. was admitted to the hospital for severe respiratory problems. The hospital filed a legal motion to appoint a guardian for the child's care, and to declare that the hospital did not need to provide any services beyond palliative care.
At the trial [Matter of Baby K. 16 F.3d 590 (4th Cir. 1994), n. 9 at 598.], expert testimony was given to demonstrate that provision of ventilator support for anencephalic infants goes beyond the accepted standard of care. The legal team for Baby K's mother adhered to a religious sanctity of life principle as the basis for their case. In a particularly controversial decision, the U. S. District Court ruled that the hospital caring for Baby K must put her on a mechanical ventilator whenever she had trouble breathing. The court interpreted the Emergency Medical Treatment and Active Labor Act (EMTALA) to require continued ventilation for the infant. The wording of this act requires that patients who present with a medical emergency must get "such treatment as may be required to stabilize the medical condition" before the patient is transferred to another facility. The court refused to take a moral or ethical position on the issue, insisting that it was only interpreting the laws as they existed. As a result of the decision, Baby K was kept alive much longer than most anencephalic babies, living to age 2½.
Some commentators on the decision argue that it effectively turned doctors into mere "instruments of technology", and took away a doctor's prerogative to make responsible, utilitarian medical decisions.
Effects of Baby K. case
-The case of Baby K. is of particular importance to clinical bioethics because of the rich variety of issues it raises: defining death, the nature of personhood, the notion of moral standing, medical futility, caregiver issues, resource allocation concerns and much more.
The dissenting judge in the legal case argued that the court should have used the condition anencephaly as the basis of the case, not the recurring subsidiary symptoms of respiratory distress. As the irreversibility of anencephaly is highly accepted in the medical community, he argued that the decision to continue (futile) care only resulted in irresponsible use of medical resources, and prolonged suffering.
-The principle of Autonomy recognizes the rights of individuals to self determination. This is rooted in society’s respect for individuals’ ability to make informed decisions about personal matters. Autonomy has become more important as social values have shifted to define medical quality in terms of outcomes that are important to the patient rather than medical professionals. The increasing importance of Autonomy can be seen as a social reaction to a “paternalistic” tradition within healthcare. Respect for autonomy is the basis for informed consent and advance directives. Autonomy can often come into conflict with Beneficence when patients disagree with recommendations that health care professionals believe are in the patient’s best interest. Individuals’ capacity for informed decision making may come into question during resolution of conflicts between Autonomy and Beneficence. The role of surrogate medical decision makers is an extension of the principle of Autonomy.
The concept of non-maleficence is embodied by the phrase, "first, do no harm," or the latin, primum non nocere. Physicians are obligated under medical ethics to not prescribe medications they know to be harmful. American physicians interpret this value to exclude the practice of euthanasia, though not all concur. Probably the most extreme example in recent history of the violation of the non-maleficence dictum was Dr. Jack Kevorkian, who was convicted of second-degree homicide in Michigan in 1998 after demonstrating active euthanasia on the TV news show, 60 Minutes.
Non-maleficence is a legally definable concept. Violation of non-maleficence is the subject of medical malpractice litigation.
Some interventions undertaken by physicians can create a positive outcome while also potentially doing harm. The combination of these two circumstances is known as the "double effect." The most applicable example of this phenomenon is the use of morphine in the dying patient. Such use of morphine can ease the pain and suffering of the patient, while simultaneously hastening the demise of the patient through suppression of the respiratory drive.
Importance of communication
Many so-called "ethical conflicts" in medical ethics are traceable back to a lack of communication. Communication breakdowns between patients and their healthcare team, between family members, or between members of the medical community, can all lead to disagreements and strong feelings. These breakdowns should be remedied, and many apparently insurmountable "ethics" problems can be solved with open lines of communication.
Many times, simple communication is not enough to resolve a conflict, and a hospital ethics committee of ad hoc nature must convene to decide a complex matter. Permanent bodies, ethical boards are established to a greater extent as ethical issues tend to increase. These bodies are comprised of health care professionals, philosophers, lay people, and still clergy.
The assignment of philosophers or clergy will reflect the importance attached by the society to the basic values involved. An example from Sweden with Torbjörn Tännsjö on a couple of such committees indicates secular trends gaining influence.
Culture differences can create difficult medical ethics problems. Some cultures have spiritual or magical theories about the origins of disease, for example, and reconciling these beliefs with the tenets of Western medicine can be difficult.
Some cultures do not place a great emphasis on informing the patient of the diagnosis, especially when cancer is the diagnosis. Even American culture did not emphasize truth-telling in a cancer case, up until the 1970s. In American medicine, the principle of informed consent takes precedence over other ethical values, and patients are usually at least asked whether they want to know the diagnosis.