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= Medical ethics =
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Introduction
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Medical ethics is a system of moral principles that apply values to
the practice of clinical medicine and in scientific research. Medical
ethics is based on a set of values that professionals can refer to in
the case of any confusion or conflict. These values include the
respect for autonomy, non-maleficence, beneficence, and justice. Such
tenets may allow doctors, care providers, and families to create a
treatment plan and work towards the same common goal. It is important
to note that these four values are not ranked in order of importance
or relevance and that they all encompass values pertaining to medical
ethics. However, a conflict may arise leading to the need for
hierarchy in an ethical system, such that some moral elements overrule
others with the purpose of applying the best moral judgement to a
difficult medical situation.
There are several codes of conduct. The Hippocratic Oath discusses
basic principles for medical professionals. This document dates back
to the fifth century BCE. Both The Declaration of Helsinki (1964) and
The Nuremberg Code (1947) are two well-known and well respected
documents contributing to medical ethics. Other important markings in
the history of Medical Ethics include 'Roe v. Wade' in 1973 and the
development of Hemodialysis in the 1960s. More recently, new
techniques for gene editing aiming at treating, preventing and curing
diseases utilizing gene editing, are raising important moral questions
about their applications in medicine and treatments as well as
societal impacts on future generations.
As this field continues to develop and change throughout history, the
focus remains on fair, balanced, and moral thinking across all
cultural and religious backgrounds around the world. Medical ethics
encompasses a practical application in clinical settings as well as
scholarly work on its history, philosophy, and sociology.
Medical ethics encompasses beneficence, autonomy, and justice as they
relate to conflicts such as euthanasia, patient confidentiality,
informed consent, and conflicts of interest in healthcare. In
addition, medical ethics and culture are interconnected as different
cultures implement ethical values differently, sometimes placing more
emphasis on family values and downplaying the importance of autonomy.
This leads to an increasing need for culturally sensitive physicians
and ethical committees in hospitals and other healthcare settings.
History
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The term medical ethics first dates back to 1803, when English author
and physician Thomas Percival published a document describing the
requirements and expectations of medical professionals within medical
facilities. The Code of Ethics was then adapted in 1847, relying
heavily on Percival's words. Over the years in 1903, 1912, and 1947,
revisions have been made to the original document. The practice of
Medical Ethics is widely accepted and practiced throughout the world.
Historically, Western medical ethics may be traced to guidelines on
the duty of physicians in antiquity, such as the Hippocratic Oath, and
early Christian teachings. The first code of medical ethics, 'Formula
Comitis Archiatrorum', was published in the 5th century, during the
reign of the Ostrogothic king Theodoric the Great. In the medieval and
early modern period, the field is indebted to Islamic scholarship such
as Ishaq ibn Ali al-Ruhawi (who wrote the 'Conduct of a Physician',
the first book dedicated to medical ethics), Avicenna's Canon of
Medicine and Muhammad ibn Zakariya ar-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, Islamic and Jewish medical ethics.
By the 18th and 19th centuries, medical ethics emerged as a more
self-conscious discourse. In England, Thomas Percival, a physician and
author, crafted the first modern code of medical ethics. He drew up a
pamphlet with the code in 1794 and wrote an expanded version in 1803,
in which he coined the expressions "medical ethics" and "medical
jurisprudence". However, there are some who see Percival's guidelines
that relate to physician consultations 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 addition, since the mid 19th century up to the
20th century, physician-patient relationships that once were more
familiar became less prominent and less intimate, sometimes leading to
malpractice, which resulted in less public trust and a shift in
decision making power from the paternalistic physician model to
today's emphasis on patient autonomy and self-determination.
In 1815, the Apothecaries Act was passed by the Parliament of the
United Kingdom. It introduced compulsory apprenticeship and formal
qualifications for the apothecaries of the day under the license of
the Society of Apothecaries. This was the beginning of regulation of
the medical profession in the UK.
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
1960s and 1970s, 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.
Well-known medical ethics cases include:
* Albert Kligman's dermatology experiments
* Deep sleep therapy
* Doctors' Trial
* 'Greenberg v. Miami Children's Hospital Research Institute'
* Henrietta Lacks
* Chester M. Southam's Cancer Injection Study
* Human radiation experiments
* Jesse Gelsinger
* 'Moore v. Regents of the University of California'
* Surgical removal of body parts to try to improve mental health
* Medical Experimentation on Black Americans
* Milgram experiment
* Radioactive iodine experiments
* The Monster Study
* Plutonium injections
* The David Reimer case
* The Stanford Prison Experiment
* Tuskegee syphilis experiment
* Willowbrook State School
* Yanomami blood sample collection
** 'Darkness in El Dorado'
Since the 1970s, the growing influence of ethics in contemporary
medicine can be seen in the increasing use of Institutional Review
Boards to evaluate experiments on human subjects, the establishment of
hospital ethics committees, the expansion of the role of clinician
ethicists, and the integration of ethics into many medical school
curricula.
Values
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A common framework used in the analysis of medical ethics is the "four
principles" approach postulated by Tom Beauchamp and James Childress
in their textbook 'Principles of biomedical ethics'. It recognizes
four basic moral principles, which are to be judged and weighed
against each other, with attention given to the scope of their
application. The four principles are:
* Respect for autonomy - the patient has the right to refuse or choose
their treatment.
* Beneficence - a practitioner should act in the best interest of the
patient.
* Non-maleficence - to not be the cause of harm. Also, "Utility" - to
promote more good than harm
* Justice - concerns the distribution of scarce health resources, and
the decision of who gets what treatment.
Autonomy
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The principle of autonomy, broken down into "autos" (self) and "nomos
(rule), views the rights of an individual to self-determination. This
is rooted in society's respect for individuals' ability to make
informed decisions about personal matters with freedom. Autonomy has
become more important as social values have shifted to define medical
quality in terms of outcomes that are important to the patient and
their family rather than medical professionals. The increasing
importance of autonomy can be seen as a social reaction against the
"paternalistic" tradition within healthcare. Some have questioned
whether the backlash against historically excessive paternalism in
favor of patient autonomy has inhibited the proper use of soft
paternalism to the detriment of outcomes for some patients.
The definition of autonomy is the ability of an individual to make a
rational, uninfluenced decision. Therefore, it can be said that
autonomy is a general indicator of a healthy mind and body. The
progression of many terminal diseases are characterized by loss of
autonomy, in various manners and extents. For example, dementia, a
chronic and progressive disease that attacks the brain can induce
memory loss and cause a decrease in rational thinking, almost always
results in the loss of autonomy.
Psychiatrists and clinical psychologists are often asked to evaluate a
patient's capacity for making life-and-death decisions at the end of
life. Persons with a psychiatric condition such as delirium or
clinical depression may lack capacity to make end-of-life decisions.
For these persons, a request to refuse treatment may be taken in the
context of their condition. Unless there is a clear advance directive
to the contrary, persons lacking mental capacity are treated according
to their best interests. This will involve an assessment involving
people who know the person best to what decisions the person would
have made had they not lost capacity. Persons with the mental capacity
to make end-of-life decisions may refuse treatment with the
understanding that it may shorten their life. Psychiatrists and
psychologists may be involved to support decision making.
Beneficence
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The term beneficence refers to actions that promote the well being of
others. In the medical context, this means taking actions that serve
the best interests of patients and their families. However,
uncertainty surrounds the precise definition of which practices do in
fact help patients.
James Childress and Tom Beauchamp in 'Principle of Biomedical Ethics'
(1978) identify beneficence as one of the core values of healthcare
ethics. Some scholars, such as Edmund Pellegrino, argue that
beneficence is the 'only' fundamental principle of medical ethics.
They argue that healing should be the sole purpose of medicine, and
that endeavors like cosmetic surgery and euthanasia are severely
unethical and against the Hippocratic Oath.
Non-maleficence
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The concept of non-maleficence is embodied by the phrase, "first, do
no harm," or the Latin, 'primum non nocere'. Many consider that should
be the main or primary consideration (hence 'primum'): that it is more
important not to harm your patient, than to do them good, which is
part of the hippocratic oath that doctors take. This is partly because
enthusiastic practitioners are prone to using treatments that they
believe will do good, without first having evaluated them adequately
to ensure they do no harm to the patient. Much harm has been done to
patients as a result, as in the saying, "The treatment was a success,
but the patient died." It is not only more important to do no harm
than to do good; it is also important to 'know' how likely it is that
your treatment will harm a patient. So a physician should go further
than not prescribing medications they know to be harmful�he or she
should not prescribe medications (or otherwise treat the patient)
unless s/he knows that the treatment is unlikely to be harmful; or at
the very least, that patient understands the risks and benefits, and
that the likely benefits outweigh the likely risks.
In practice, however, many treatments carry some risk of harm. In some
circumstances, e.g. in desperate situations where the outcome without
treatment will be grave, risky treatments that stand a high chance of
harming the patient will be justified, as the risk of not treating is
also very likely to do harm. So the principle of 'non-maleficence' is
not absolute, and balances against the principle of 'beneficence'
(doing good), as the effects of the two principles together often give
rise to a 'double effect' (further described in next section). Even
basic actions like taking a blood sample or an injection of a drug
cause harm to the patient's body. Euthanasia also goes against the
principle of beneficence because the patient dies as a result of the
medical treatment by the doctor.
Double effect
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'Double effect' refers to two types of consequences that may be
produced by a single action, and in medical ethics it is usually
regarded as the combined effect of beneficence and non-maleficence.
A commonly cited example of this phenomenon is the use of morphine or
other analgesic in the dying patient. Such use of morphine can have
the beneficial effect of easing the pain and suffering of the patient
while simultaneously having the maleficent effect of shortening the
life of the patient through the deactivation of the respiratory
system.
Respect for human rights
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The human rights era started with the formation of the United Nations
in 1945, which was charged with the promotion of human rights. The
Universal Declaration of Human Rights (1948) was the first major
document to define human rights. Medical doctors have an ethical duty
to protect the human rights and human dignity of the patient so the
advent of a document that defines human rights has had its effect on
medical ethics. Most codes of medical ethics now require respect for
the human rights of the patient.
The Council of Europe promotes the rule of law and observance of human
rights in Europe. The Council of Europe adopted the 'European
Convention on Human Rights and Biomedicine' (1997) to create a uniform
code of medical ethics for its 47 member-states. The Convention
applies international human rights law to medical ethics. It provides
special protection of physical integrity for those who are unable to
consent, which includes children.
No organ or tissue removal may be carried out on a person who does not
have the capacity to consent under Article 5.
As of December 2013, the Convention had been ratified or acceded to by
twenty-nine member-states of the Council of Europe.
The United Nations Educational, Scientific and Cultural Organization
(UNESCO) also promotes the protection of human rights and human
dignity. According to UNESCO, "Declarations are another means of
defining norms, which are not subject to ratification. Like
recommendations, they set forth universal principles to which the
community of States wished to attribute the greatest possible
authority and to afford the broadest possible support." UNESCO adopted
the 'Universal Declaration on Human Rights and Biomedicine' to advance
the application of international human rights law in medical ethics.
The Declaration provides special protection of human rights for
incompetent persons.
In applying and advancing scientific knowledge, medical practice and
associated technologies, human vulnerability should be taken into
account. Individuals and groups of special vulnerability should be
protected and the personal integrity of such individuals respected.
Solidarity
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The more individualistic standards of autonomy and personal human
rights as they relate to social justice seen in the Anglo-Saxon
community, clash with and can also supplement the concept of
solidarity, which stands closer to a European healthcare perspective
focused on community, universal welfare, and the unselfish wish to
provide healthcare equally for all. In the United States
individualistic and self-interested healthcare norms are upheld,
whereas in other countries, including European countries, a sense of
respect for the community and personal support is more greatly upheld
in relation to free healthcare.
Acceptance of Ambiguity in Medicine
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The concept of normality, that there is a human physiological standard
contrasting with conditions of illness, abnormality and pain, leads to
assumptions and bias that negatively affects health care practice. It
is important to realize that normality is ambiguous and that ambiguity
in healthcare and the acceptance of such ambiguity is necessary in
order to practice humbler medicine and understand complex, sometimes
unusual usual medical cases. Thus, society�s views on central
concepts in philosophy and clinical beneficence must be questioned and
revisited, adopting ambiguity as a central player in medical practice.
Between autonomy and beneficence/non-maleficence
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Autonomy can come into conflict with beneficence when patients
disagree with recommendations that healthcare professionals believe
are in the patient's best interest. When the patient's interests
conflict with the patient's welfare, different societies settle the
conflict in a wide range of manners. In general, Western medicine
defers to the wishes of a mentally competent patient to make their own
decisions, even in cases where the medical team believes that they are
not acting in their own best interests. However, many other societies
prioritize beneficence over autonomy.
Examples include when a patient does not want a treatment because of,
for example, religious or cultural views. In the case of euthanasia,
the patient, or relatives of a patient, may want to end the life of
the patient. Also, the patient may want an unnecessary treatment, as
can be the case in hypochondria or with cosmetic surgery; here, the
practitioner may be required to balance the desires of the patient for
medically unnecessary potential risks against the patient's informed
autonomy in the issue. A doctor may want to prefer autonomy because
refusal to please the patient's self-determination would harm the
doctor-patient relationship.
Organ donations can sometimes pose interesting scenarios, in which a
patient is classified as a non-heart beating donors (NHBD), where life
support fails to restore the heartbeat and is now considered futile
but brain death has not occurred. Classifying a patient as a NHBD can
qualify someone to be subject to non-therapeutic intensive care, in
which treatment is only given to preserve the organs that will be
donated and not to preserve the life of the donor. This can bring up
ethical issues as some may see respect for the donors wishes to donate
their healthy organs as respect for autonomy, while others may view
the sustaining of futile treatment during vegetative state maleficence
for the patient and the patient's family. Some are worried making this
process a worldwide customary measure may dehumanize and take away
from the natural process of dying and what it brings along with it.
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.
On the other hand, autonomy and beneficence/non-maleficence may also
overlap. For example, a breach of patients' autonomy may cause
decreased confidence for medical services in the population and
subsequently less willingness to seek help, which in turn may cause
inability to perform beneficence.
The principles of autonomy and beneficence/non-maleficence may also be
expanded to include effects on the relatives of patients or even the
medical practitioners, the overall population and economic issues when
making medical decisions.
Euthanasia
============
There is disagreement among American physicians as to whether the
non-maleficence principle excludes the practice of euthanasia.
Euthanasia is currently legal in the states of Washington DC,
California, Colorado, Oregon, Vermont, and Washington. Around the
world, there are different organizations that campaign to change
legislation about the issue of physician-assisted death, or PAD.
Examples of such organizations are the Hemlock Society of the United
States and the Dignity in Dying campaign in the United Kingdom. These
groups believe that doctors should be given the right to end a
patient's life only if the patient is conscious enough to decide for
themselves, is knowledgeable about the possibility of alternative
care, and has willingly asked to end their life or requested access to
the means to do so.
This argument is disputed in other parts of the world. For example, in
the state of Louisiana, giving advice or supplying the means to end a
person's life is considered a criminal act and can be charged as a
felony. In state courts, this crime is comparable to manslaughter. The
same laws apply in the states of Mississippi and Nebraska.
Informed consent
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Informed consent in ethics usually refers to the idea that a person
must be fully informed about and understand the potential benefits and
risks of their choice of treatment. A correlate to "informed consent"
is the concept of informed refusal. An uninformed person is at risk of
mistakenly making a choice not reflective of his or her values or
wishes. It does not specifically mean the process of obtaining
consent, or the specific legal requirements, which vary from place to
place, for capacity to consent. Patients can elect to make their own
medical decisions or can delegate decision-making authority to another
party. If the patient is incapacitated, laws around the world
designate different processes for obtaining informed consent,
typically by having a person appointed by the patient or their next of
kin make decisions for them. The value of informed consent is closely
related to the values of autonomy and truth telling.
Confidentiality
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Confidentiality is commonly applied to conversations between doctors
and patients. This concept is commonly known as patient-physician
privilege. Legal protections prevent physicians from revealing their
discussions with patients, even under oath in court.
Confidentiality is mandated in the United States by the Health
Insurance Portability and Accountability Act of 1996 known as HIPAA,
specifically the Privacy Rule, and various state laws, some more
rigorous than HIPAA. However, numerous exceptions to the rules have
been carved out over the years. For example, many states require
physicians to report gunshot wounds to the police and impaired drivers
to the Department of Motor Vehicles. Confidentiality is also
challenged in cases involving the diagnosis of a sexually transmitted
disease in a patient who refuses to reveal the diagnosis to a spouse,
and in the termination of a pregnancy in an underage patient, without
the knowledge of the patient's parents. Many states in the U.S. have
laws governing parental notification in underage abortion.
Traditionally, medical ethics has viewed the duty of confidentiality
as a relatively non-negotiable tenet of medical practice. More
recently, critics like Jacob Appel have argued for a more nuanced
approach to the duty that acknowledges the need for flexibility in
many cases.
Confidentiality is an important issue in primary care ethics, where
physicians care for many patients from the same family and community,
and where third parties often request information from the
considerable medical database typically gathered in primary health
care.
Healthcare practice and privacy in an Online World
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In increasing frequency, medical researchers are researching
activities in online environments such as discussion boards and
bulletin boards, and there is concern that the requirements of
informed consent and privacy are not applied, although some guidelines
do exist.
One issue that has arisen, however, is the disclosure of information.
While researchers wish to quote from the original source in order to
argue a point, this can have repercussions when the identity of the
patient is not kept confidential. The quotations and other information
about the site can be used to identify the patient, and researchers
have reported cases where members of the site, bloggers and others
have used this information as 'clues' in a game in an attempt to
identify the site. Some researchers have employed various methods of
"heavy disguise." including discussing a different condition from that
under study.
Healthcare institutions' websites have the responsibility to ensure
that the private medical records of their online visitors are secure
from being marketed and monetized into the hands of drug companies,
occupation records, and insurance companies. The delivery of diagnosis
online leads patients to believe that doctors in some parts of the
country are at the direct service of drug companies, finding diagnosis
as convenient as what drug still has patent rights on it. Physicians
and drug companies are found to be competing for top ten search engine
ranks to lower costs of selling these drugs with little to no patient
involvement.
With the expansion of internet healthcare platforms, online
practitioner legitimacy and privacy accountability face unique
challenges such as e-paparazzi, online information brokers, industrial
spies, unlicensed information providers that work outside of
traditional medical codes for profit. The American Medical Association
(AMA) states that medical websites have the responsibility to ensure
the health care privacy of online visitors and protect patient records
from being marketed and monetized into the hands of insurance
companies, employers, and marketers. [40] With the rapid unification
of healthcare, business practices, computer science and e-commerce to
create these online diagnostic websites, efforts to maintain health
care system's ethical confidentiality standard need to keep up as
well. Over the next few years, the Department of Health and Human
Services have stated that they will be working towards lawfully
protecting the online privacy and digital transfers of patient
Electronic Medical Records (EMR) under The Health Insurance
Portability and Accountability Act (HIPAA). [41]
Control and resolution
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To ensure that appropriate ethical values are being applied within
hospitals, effective hospital accreditation requires that ethical
considerations are taken into account, for example with respect to
physician integrity, conflict of interest, research ethics and organ
transplantation ethics.
Guidelines
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There is much documentation of the history and necessity of the
Declaration of Helsinki. The first code of conduct for research
including medical ethics was the Nuremberg Code. This document had
large ties to Nazi war crimes, as it was introduced in 1947, so it
didn't make much of a difference in terms of regulating practice. This
issue called for the creation of the Declaration. There are some stark
differences between the Nuremberg Code and the Declaration of
Helsinki, including the way it is written. Nuremberg was written in a
very concise manner, with a simple explanation. The Declaration of
Helsinki is written with a thorough explanation in mind and including
many specific commentaries.
In the United Kingdom, General Medical Council provides clear overall
modern guidance in the form of its 'Good Medical Practice' statement.
Other organizations, such as the Medical Protection Society and a
number of university departments, are often consulted by British
doctors regarding issues relating to ethics.
Ethics committees
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Often, simple communication is not enough to resolve a conflict, and a
hospital ethics committee must convene to decide a complex matter.
These bodies are composed primarily of healthcare professionals, but
may also include philosophers, lay people, and clergy - indeed, in
many parts of the world their presence is considered mandatory in
order to provide balance.
With respect to the expected composition of such bodies in the US,
Europe and Australia, the following applies.
U.S. recommendations suggest that Research and Ethical Boards (REBs)
should have five or more members, including at least one scientist,
one non-scientist, and one person not affiliated with the institution.
The REB should include people knowledgeable in the law and standards
of practice and professional conduct. Special memberships are
advocated for handicapped or disabled concerns, if required by the
protocol under review.
The European Forum for Good Clinical Practice (EFGCP) suggests that
REBs include two practicing physicians who share experience in
biomedical research and are independent from the institution where the
research is conducted; one lay person; one lawyer; and one paramedical
professional, e.g. nurse or pharmacist. They recommend that a quorum
include both sexes from a wide age range and reflect the cultural
make-up of the local community.
The 1996 Australian Health Ethics Committee recommendations were
entitled, "Membership Generally of Institutional Ethics Committees".
They suggest a chairperson be preferably someone not employed or
otherwise connected with the institution. Members should include a
person with knowledge and experience in professional care, counseling
or treatment of humans; a minister of religion or equivalent, e.g.
Aboriginal elder; a layman; a laywoman; a lawyer and, in the case of a
hospital-based ethics committee, a nurse.
The assignment of philosophers or religious clerics 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.
Cultural concerns
======================================================================
Culture differences can create difficult medical ethics problems. Some
cultures have spiritual or magical theories about the origins and
cause of disease, for example, and reconciling these beliefs with the
tenets of Western medicine can be very difficult. As different
cultures continue to intermingle and more cultures live alongside each
other, the healthcare system, which tends to deal with important life
events such as birth, death and suffering, increasingly experiences
difficult dilemmas that can sometimes lead to cultural clashes and
conflict. Efforts to respond in a culturally sensitive manner go hand
in hand with a need to distinguish limits to cultural tolerance.
Culture and Language
======================
As more people from different cultural and religious backgrounds move
to other countries, among these, the United States, it is becoming
increasingly important to be culturally sensitive to all communities
in order to provide the best health care for all people. Lack of
cultural knowledge can lead to misunderstandings and even inadequate
care, which can lead to ethical problems. A common complaint patients
have is feeling like they are not being heard, or perhaps, understood.
Preventing escalating conflict can be accomplished by seeking
interpreters, noticing body language and tone of both yourself and the
patient as well as attempting to understand the patient's perspective
in order to reach an acceptable option.
Some believe most medical practitioners in the future will have to be
or greatly benefit from being bilingual. In addition to knowing the
language, truly understanding culture is best for optimal care.
Recently, a practice called 'narrative medicine' has gained some
interest as it has a potential for improving patient-physician
communication and understanding of patient's perspective. Interpreting
a patient's stories or day to day activities as opposed to
standardizing and collecting patient data may help in acquiring a
better sense of what each patient needs, individually, with respect to
their illness. Without this background information, many physicians
are unable to properly understand the cultural differences that may
set two different patients apart, and thus, may diagnose or recommend
treatments that are culturally insensitive or inappropriate. In short,
patient narrative has the potential for uncovering patient information
and preferences that may otherwise be overlooked.
Medical humanitarianism
=========================
In order to address the undeserved, uneducated communities in need of
nutrition, housing, and healthcare disparities seen in much of the
world today, some argue that we must fall back on ethical values in
order to create a foundation to move towards a reasonable
understanding, which encourages commitment and motivation to improve
factors causing premature death as a goal in a global community. Such
factors -such as poverty, environment and education- are said to be
out of national or individual control and so this commitment is by
default a social and communal responsibility placed on global
communities that are able to aid others in need. This is based on the
framework of 'provincial globalism,' which seeks a world in which all
people have the capability to be healthy.
One concern regarding the intersection of medical ethics and
humanitarian medical aid is how medical assistance can be as harmful
as it is helpful to the community being served. One such example being
how political forces may control how foreign humanitarian aid can be
utilized in the region it is meant to be provided in. This would be
congruous in situations where political strife could lead such aid
being used in favor of one group over another. Another example of how
foreign humanitarian aid can be misused in its intended community
includes the possibility of dissonance forming between a foreign
humanitarian aid group and the community being served. Examples of
this could include the relationships being viewed between aid workers,
style of dress, or the lack of education regarding local culture and
customs.
Humanitarian practices in areas lacking optimum care can also pause
other interesting and difficult ethical dilemmas in terms of
beneficence and non-maleficence. Humanitarian practices are based upon
providing better medical equipment and care for communities who's
country does not provide adequate healthcare. The issues with
providing healthcare to communities in need may sometimes be religious
or cultural backgrounds keeping people from performing certain
procedures or taking certain drugs. On the other hand, wanting certain
procedures done in a specific manner due to religious or cultural
belief systems may also occur. The ethical dilemma stems from
differences in culture between communities helping those with medical
disparities and the societies receiving aid. Women's rights, informed
consent and education about health become controversial, as some
treatments needed are against societal law, while some cultural
traditions involve procedures against humanitarian efforts. Examples
of this are female genital mutilation (FGM), aiding in reinfibulation,
providing sterile equipment in order to perform procedures such as
FGM, as well as informing patients of their HIV positive testing. The
latter is controversial because certain communities have in the past
outcast or killed HIV positive individuals.
Healthcare reform and Lifestyle
=================================
Leading causes of death in the United States and around the world are
highly related to behavioral consequences over genetic or
environmental factors. This leads some to believe true healthcare
reform begins with cultural reform, habit and overall lifestyle.
Lifestyle, then, becomes the cause of many illnesses and the illnesses
themselves are the result or side-effect of a larger problem. Some
people believe this to be true and think that cultural change is
needed in order for developing societies to cope and dodge the
negative effects of drugs, food and conventional modes of
transportation available to them. In 1990, tobacco use, diet, and
exercise alone accounted for close to 80 percent of all premature
deaths and continue to lead in this way though the 21st century. Heart
disease, stroke, dementia, and diabetes are some of the diseases that
may be affected by habit forming patters throughout our life. Some
believe that medical lifestyle counseling and building healthy habits
around our daily lives is one way to tackle health care reform.
Buddhist medicine
===================
Buddhist ethics and medicine are based on religious teachings of
compassion and understanding of suffering and cause and effect and the
idea that there is no beginning or end to life, but that instead there
are only rebirths in an endless cycle. In this way, death is merely a
phase in an indefinitely lengthy process of life, not an end. However,
Buddhist teachings support living ones life to the fullest so that
through all the suffering which encompasses a large part of what is
life, there are no regrets. Buddhism accepts suffering as an
inescapable experience, but values happiness and thus values life.
Because of this suicide, and euthanasia, are prohibited. However,
attempts to rid oneself of any physical or mental pain and suffering
are seen as good acts. On the other hand sedatives and drugs are
thought to impair consciousness and awareness in the dying process,
which is believed to be of great importance, as it is thought that
one's dying consciousness remains and affects new life. Because of
this, analgesics must not be part of the dying process, in order for
the dying person to be present entirely and pass on their
consciousness wholesomely. This can pose significant conflicts during
end of life care in Western medical practice.
Chinese Medicine
==================
In traditional Chinese philosophy, human life is believed to be
connected to nature, which is thought of as the foundation and
encompassing force sustaining all of life's phases. Passing and coming
of the seasons, life, birth and death are perceived as a cyclic and
perpetual occurrences that are believed to be regulated by the
principles of 'yin' and 'yang''.' When one dies, the life-giving
material force referred to as 'ch'i', encompassing both body and
spirit, rejoins the material force of the universe and cycles on with
respect to the rhythms set forth by 'yin' and 'yang.'
Because many Chinese people believe that circulation of both physical
and 'psychic energy' is important to stay health, procedures which
require surgery as well as donations and trans-plantations of organs
are seen as a loss of 'ch'i' , resulting in the loss of someone's
vital energy supporting their consciousness and purpose in their
lives. Furthermore, a person is never seen as a single unit but rather
as a source of relationship, interconnected in a social web. Thus, it
is believed that what makes a human one of us is relatedness and
communication and family is seen as the basic unit of a community.
This can greatly affect the way medical decisions are made among
family members, as diagnoses are not always expected to be announced
to the dying or sick, the elderly are expected to be cared for and
represented by their children and physicians are expected to act in a
paternalistic way. In short, informed consent as well as patient
privacy can be difficult to enforce when dealing with Confucian
families.
Furthermore, some Chinese people may be inclined to continue futile
treatment in order to extend life and allow for fulfillment of the
practice of benevolence and humanity. In contrast, patients with
strong Daoist beliefs may see death as an obstacle and dying as a
reunion with nature that should be accepted, and are therefore less
likely to ask for treatment of an irreversible condition.
Islamic culture and medicine
==============================
Some believe Islamic medical ethics and framework remain poorly
understood by many working in healthcare. It is important to recognize
that for people of Islamic faith, Islam envelops and affects all
aspects of life, not just medicine. Because many believe it is faith
and a supreme deity that hold the cure to illness, it is common that
the physician is viewed merely as help or intermediary player during
the process of healing or medical care.
In addition to Chinese culture's emphasis on family as the basic unit
of a community intertwined and forming a greater social construct,
Islamic traditional medicine also places importance on the values of
family and the well-being of a community. Many Islamic communities
uphold paternalism as an acceptable part of medical care. However,
autonomy and self-rule is also valued and protected and, in Islamic
medicine, it is particularly upheld in terms of providing and
expecting privacy in the healthcare setting. An example of this is
requesting same gender providers in order to retain modesty. Overall,
Beauchamp's principles of beneficence, non-maleficence and justice
are promoted and upheld in the medical sphere with as much importance
as in Western culture. In contrast, autonomy is important but more
nuanced. Furthermore, Islam also brings forth the principles of
jurisprudence, Islamic law and legal maxims, which also allow for
Islam to adapt to an ever-changing medical ethics framework.
Conflicts of interest
======================================================================
Physicians should not allow a conflict of interest to influence
medical judgment. In some cases, conflicts are hard to avoid, and
doctors have a responsibility to avoid entering such situations.
Research has shown that conflicts of interests are very common among
both academic physicians and physicians in practice.
Referral
==========
Doctors who receive income from referring patients for medical tests
have been shown to refer more patients for medical tests. This
practice is proscribed by the American College of Physicians Ethics
Manual. Fee splitting and the payments of commissions to attract
referrals of patients is considered unethical and unacceptable in most
parts of the world.
Vendor relationships
======================
Studies show that doctors can be influenced by drug company
inducements, including gifts and food. Industry-sponsored Continuing
Medical Education (CME) programs influence prescribing patterns. Many
patients surveyed in one study agreed that physician gifts from drug
companies influence prescribing practices. A growing movement among
physicians is attempting to diminish the influence of pharmaceutical
industry marketing upon medical practice, as evidenced by Stanford
University's ban on drug company-sponsored lunches and gifts. Other
academic institutions that have banned pharmaceutical
industry-sponsored gifts and food include the Johns Hopkins Medical
Institutions, University of Michigan, University of Pennsylvania, and
Yale University.
Treatment of family members
=============================
The American Medical Association (AMA) states that "Physicians
generally should not treat themselves or members of their immediate
family". This code seeks to protect patients and physicians because
professional objectivity can be compromised when the physician is
treating a loved one. Studies from multiple health organizations have
illustrated that physician-family member relationships may cause an
increase in diagnostic testing and costs. Many doctors still treat
their family members. Doctors who do so must be vigilant not to create
conflicts of interest or treat inappropriately. Physicians that treat
family members need to be conscious of conflicting expectations and
dilemmas when treating relatives, as established medical ethical
principles may not be morally imperative when family members are
confronted with serious illness.
Sexual relationships
======================
Sexual relationships between doctors and patients can create ethical
conflicts, since sexual consent may conflict with the fiduciary
responsibility of the physician. Out of the many disciplines in
current medicine, there are studies that have been conducted in order
to ascertain the occurrence of Doctor-Patient sexual misconduct.
Results from those studies appear to indicate that certain disciplines
are more likely to be offenders than others. Psychiatrists and
Obstetrician-Gynecologists for example, are two disciplines noted for
having a higher rate of sexual misconduct. The violation of ethical
conduct between doctors and patients also has an association with the
age and sex of doctor and patient. Male physicians aged 40-49 and
50-59 years are two groups that have been found to be more likely to
have been reported for sexual misconduct, while women aged 20-39 have
been found to make up a significant portion of reported victims of
sexual misconduct. Doctors who enter into sexual relationships with
patients face the threats of losing their medical license and
prosecution. In the early 1990s, it was estimated that 2-9% of doctors
had violated this rule. Sexual relationships between physicians and
patients' relatives may also be prohibited in some jurisdictions,
although this prohibition is highly controversial.
Futility
======================================================================
In some hospitals, medical futility is referred to as treatment unable
to benefit the patient. An important part of practicing good medical
ethics is by attempting to avoid futility by practicing
non-maleficence. What should be done if there is no chance that a
patient will survive or benefit from a potential treatment but the
family members insist on advanced care? Previously, some articles
defined futility as the patient having less than a one percent chance
of surviving. Some of these cases are examined in court.
Advance directives include living wills and durable powers of attorney
for health care. ('See also Do Not Resuscitate and cardiopulmonary
resuscitation') In many cases, the "expressed wishes" of the patient
are documented in these directives, and this provides a framework to
guide family members and health care professionals in the
decision-making process when the patient is incapacitated.
Undocumented expressed wishes can also help guide decisions in the
absence of advance directives, as in the Quinlan case in Missouri.
"Substituted judgment" is the concept that a family member can give
consent for treatment if the patient is unable (or unwilling) to give
consent themselves. The key question for the decision-making surrogate
is not, "What would you like to do?", but instead, "What do you think
the patient would want in this situation?".
Courts have supported family's arbitrary definitions of futility to
include simple biological survival, as in the Baby K case (in which
the courts ordered a child born with only a brain stem instead of a
complete brain to be kept on a ventilator based on the religious
belief that all life must be preserved).
Baby Doe Law establishes state protection for a disabled child's right
to life, ensuring that this right is protected even over the wishes of
parents or guardians in cases where they want to withhold treatment.
See also
======================================================================
* Applied ethics
* Bioethics
* 'The Citadel'
* 'Clinical Ethics'
* Clinical governance
* Do not resuscitate
* Empathy
* Ethical code
* Ethics of circumcision
* Euthanasia
* Evidence-based medical ethics
* Fee splitting
* Hastings Center
* Health ethics
* Hippocratic Oath
* Human radiation experiments
* Islamic bioethics
* Jewish medical ethics
* Joint Commission International, JCI
* MacLean Center for Clinical Medical Ethics
* Medical Code of Ethics
* Medical Law International
* Medical law
* Medical torture
** Pharmacological torture
* Military medical ethics
* Nursing ethics
* Patient abuse
* Philosophy of Healthcare
* Political abuse of psychiatry
* Project MKULTRA
* Research ethics consultation
* Resources for clinical ethics consultation
* Right to health
* Seven Sins of Medicine
* U.S. patients' bill of rights
* UN Principles of Medical Ethics
* Unethical human experimentation
* World Medical Association
Reproductive medicine
=======================
* Abortion / Abortion debate
* Eugenics
* Gene splicing
* Human cloning
* Human genetic engineering
Medical research
==================
* Animal testing
* Children in clinical research
* CIOMS Guidelines
* Clinical Equipoise
* Clinical research ethics
* Declaration of Geneva
* Declaration of Helsinki
* Declaration of Tokyo
* Ethical problems using children in clinical trials
* First-in-man study
* Good clinical practice
* Health Insurance Portability and Accountability Act
* Institutional Review Board
* Nuremberg Code
* Research ethics consultation
* Universal Declaration of Human Rights
Sources and references
======================================================================
*Beauchamp, Tom L., and Childress, James F. 2001. 'Principles of
Biomedical Ethics'. New York: Oxford University Press.
*
*Brody, Baruch A. 1988. 'Life and Death Decision Making'. New York:
Oxford University Press.
*Curran, Charles E. "The Catholic Moral Tradition in Bioethics" in
Walter and Klein (below).
*
*
*
* See especially chapter 1, "Historical background to the discipline."
*
*
*
*
*
External links
======================================================================
*
* [
http://www.who.int/ethics/en/ Global health ethics] at World Health
Organization
* [
http://www.iep.utm.edu/h-c-ethi/ Health Care Ethics] article in the
'Internet Encyclopedia of Philosophy'
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Original Article:
http://en.wikipedia.org/wiki/Medical_ethics
