Encyclopedia of Ethics. Lawrence and
Charlotte Becker, eds. 2nd edition. Garland 1998
Until recently, philosophers took little interest in medical practice or physicians' codes of ethics. Since the 1960's, however, they have joined physicians, theologians, and lawyers in founding journals, research centers, hospital and medical school committees, departments, programs, and special degrees in medical ethics, primarily in North America but increasingly world-wide. This exponential growth invites differentiation of medical ethics (primarily, physician-centered) and health care ethics (including nurses and other healthcare providers), clinical ethics (focused on hospital case decisions with the aid of diverse committees and consultants), and bioethics (including general issues of reproduction, fair distribution of organs and other scarce life-saving resources, and protection of the biosphere).
Principal topics in medical ethics include: physicians paternalistic deceptions and violations of patient confidentiality; the rights of patients or their surrogates to refuse life-sustaining treatments or request assistance in dying; drug experiments on children, demented or dying patients, and other incompetent or desperate patients; bias-free definitions of health, death, disease, and futility of treatment; removing viable organs from patients who are brain dead or in cardiac arrest; grounds for fetal testing, selection, and abortion; involuntary hospitalization and treatment of mentally disturbed people; conflicts of interest between physicians and their employers and third-party payers, public and private.
Physician-philosopher collaboration on this range of topics has posed meta-ethical questions about the role of professional codes, religious principles, ethical theories and principles, committee consensus, clinical experience, and moral intuitions in the analysis and decision of clinical cases. As clinicians increasingly share or preempt medical ethics teaching in medical schools, the issue of appropriate philosophical training has arisen.
Physicians and Patients
Traditional medical oaths and codes prescribe a physician's character, motives, and duties. Typically they portray ideal physicians as devoted to the welfare of patients and to advancement of the medical profession and medical knowledge, responding compassionately to the suffering of patients, humbly mindful of the limits of their curative powers and the harms they may unintentionally cause. The Hippocratic injunction "Strive to help, but above all, do no harm" is the ruling maxim. In current discussion, this maxim has been codified in oft-cited "principles of nonmaleficence and beneficence."
Although still supported by religious texts and medical tradition, this ideal physician is increasingly criticized as "paternalistic," too willing to act on judgments of a patient's best interests without the patient's knowledge or consent. To treat without consulting a patient is to assume that a patient does or should share one's own assessment of the risks, benefits, and burdens of treatment. But current hospital specialists, it is said, rarely know their patients (or themselves) well enough to make this assumption without serious risk of ignorant arrogance. Given hospital hierarchies, such paternalistic physicians are seen to resemble Victorian patriarchs.
Some physicians reject such criticism as intervention by lawyers, philosophers, feminists, and other social critics ignorant of the realities of medical and hospital life. But the "neo-paternalists" admit that physicians should attend more carefully to a patient's desires and to give them greater weight in arriving at a treatment of choice. Unmollified critics, however, continue to insist that treatment choice belongs to the patient, however imprudent, and not to the physician, however attentive and knowing. to curb Hippocratic paternalism they define a range of patients' specific rights to be told about, and choose among, alternative treatments, including a right to refuse all, even life-saving treatment.
These rights confer adult status on patients whom paternalists regard as children, replacing quasi-familial with quasi-legal relations. A patient's "free and informed consent" reflects an implicit therapeutic contract, defined and reviewed as treatment proceeds. A physician who treats without such consent is not a patriarch, but a batterer. Less litigously, these rights define a "principle of autonomy" traced to Kantian notions of respect for persons and inherent human dignity.
Attempts to apply this principle have raised questions of scope: Is a patient's "free and informed consent" needed for routine procedures with slight or rare risks? Is consent required if a patient would, in the physician's judgment, be "medically harmed" by information about diagnosis and prognosis? Are refusals to be honored even if patients risk death, as do surgical patients religiously opposed to blood transfusion? Does the principle (contra Kant) cover voluntary euthanasia? Can children or mentally ill patients give informed consent at least for some procedures? Can parents or other surrogates give or refuse "substituted" consent when a patient is too ill to consider the options or to speak.
Whatever the scope of a principle of patient autonomy, this challenge to paternalism has shifted the categories of concern. Physicians' power, not their character, has become the issue. Consequently, "Who is to decide?" has become more pressing than "What is to be done?" Proper procedure has become as important, in medical ethics, as correct conclusions.
Physicians and Institutions
These shifts reflect changes in medical practice from home and office to hospital and clinic. Physicians have become members of teams treating patients in institutions governed by internal routines and external guidelines from government, insurers, and corporate owners (and, secondarily, religious authorities in some instances). Increasingly decisions are delegated to "bioethics committees" which include nurses, lawyers, social workers, chaplains, philosophers, citizen representatives, patient advocates, and other non-physicians. Even if physicians dominate these care teams and hospital committees, their moral virtues or religious faith no longer confer moral authority. Any decisions must be articulate, defensible for both content and procedure and often, even in religious medical centers, by secular considerations.
Among specific institutional and procedural questions are: On what grounds (and by whom) are patients to be judged "decisionally incompetent"? How are surrogates for the incompetent patient to be chosen and their "substituted judgments" to be assessed? Should candidates for organ transplants be selected by committee, and, if so, who should sit on these committees? Should scarce or costly hospital resources be allocated by medical benefit alone? Or should quality of life, social desert or worth, or age be taken into account? When should allocation be decided by a policy of first come, first served or other chance mechanisms? Is the goal of profit-maximization by which corporations define their fiduciary responsibility to shareholders reconcilable with the goals of insuring or providing adequate care to a range of patients with a variety of ailments?
Physicians and Society
These clinical or micro-matters lead to larger issues of medicine as a public good, publicly supported and allocated. The increasing scope and costs of hospital medicine have prompted restraint and rationing in matters of drug prescriptions, elective surgery, in-patient hospital stays, out-patient services. In response, philosophers have proposed contractarian and natural law rationales for age-relative distributions, as well as utilitarian analyses of cost-efficient allocations of treatment and research funds.
These macro-issues raise questions about physician's social and political responsibilities. Most physicians recognize narrow public health and safety obligations to report a patient's communicable diseases, gunshot wounds, signs of child abuse, or serious violent intentions socially motivated exceptions to traditional pledges of confidentiality. But what of obligations to work toward a more just system of healthcare? Such a system might well limit both physician income and professional choices even more than current corporate organization of medical care in the United States. Physicians might, for example, be less free to refuse poor or poorly insured patients. Physician autonomy would become subject to a redefined, or renewed "social contract" between the profession and the society which educates, licenses, and grants its various privileges. (General professional ethics addresses such contracts and privileges.)
As these social issues emerge, medical ethics becomes less focused on the doctor at the bedside. Relationships between doctor and patient are increasingly linked with those between doctor and hospital, hospital and insurer or corporate owners and stockholders, and the ill and the healthy members of society, the rich and the poor. In short, the field has become less iatrocentric, expanding into the larger domain of health care ethics and clinical ethics.
Metaethical and Pedagogic Issues
Medical centers are a primary context for medical ethics, as well as medical care. Whether physicians, philosophers, or theologians, most medical ethicists are primarily based in medical schools and teaching hospitals, and their principal audiences are (apart from one another) medical students and residents. This setting partially explains the primary role of actual case analysis in medical ethics, by contrast with much ethical writing. Physicians and nurses have little patience with the theoretical dialectic or fanciful test-cases that constitute much current secular ethics.
Nor do they readily accept the main theoretical alternatives. The Kantian ideal of persons as rational ends-in-themselves is hard to reconcile with the reality of patients whose mature judgment, sense of self and self-interests, and dignity are subverted by illness. Likewise, the scope of the Hippocratic maxim, "Strive to help but above all, do no harm" is far narrower than the Utilitarian principle, "Everyone counts for one and no more than one." Some physicians will give some weight to the welfare of a patient's family, hospital staff, or future patients (e.g. in drug trials unlikely to benefit current patients), but they will almost certainly ignore the friends, heirs or employers who may be seriously affected by treatment decisions.
In the light of practitioners' resistance, some medical ethicists have forsaken ethical theories that have a single, dominant principle in favor of the jurists tactic of "balancing" several unranked principles. Decisions are to be reached by "weighing" for each case the now canonical principles of autonomy, beneficence, and non-maleficence, and, when appropriate, veracity, sanctity of life, and distributive justice.
Critics find this procedure too dependent on individual intuition, and have proposed various remedies. On one proposal, conflicting general principles are "specified" to yield compatible norms for a specific case. On another, the general principles are supplemented or replaced by a larger number of prohibitions drawn from "common sense" morality. On a "bottom up" alternative drawn from Medieval casuistry, it is richly described paradigm cases, not principles, that have the central role in moral reasoning. Other proposals would dispense with principles altogether in favor of professional virtues (integrity, fiduciary responsibility, compassion); the central concerns of "care ethics" (response to need, dependency, trust); and/or "narratives" sensitively constructed from conversations with patients, families, and other attendants.
All of these approaches have theoretical aspects and arguments, but the less the explicit appeal to carefully formulated and supported moral principles, the less that special philosophical training may seem necessary for case analysis. Philosophers, of course, pride themselves on their clarity, sense of relevance, and stock of apt questions and distinctions, but so too do lawyers. Moreover, medical ethicists liberally borrow notions and cases from the law (due care, act/omission, competence; Quinlan, Cruzan, Baby Does, Joyce Brown). There are, however, differences due as much to training as to institutional positions: philosophers give less weight than do "legal risk managers" to institutional interests in deciding contentious cases or formulating policy. On the other hand, medical ethicists may give more weight to institutional interests and physician practices than those bioethicists whose concerns are general issues of the creating, saving, and taking of life, with or without physicians assistance.
The content and methods of medical ethics teaching varies with audience and locale. In philosophy department classes, cases are used to raise general, often abstract issues of moral reasoning and moral theory, the definition of central concepts (autonomy, death, causal connection), and metaphysical presuppositions (personal identify, body-mind relations). In most medical schools, there is little appetite for such abstract matters, and too little curricular time to convince students and clinical co-teachers of their relevance to the pressing clinical issues and cases at hand. We should not be surprised there is no Socratic dialogue with Hippocrates.
Arras, John D., and Bonnie Steinbock, eds. Ethical Issues in Modern Medicine. 5th ed. Mountain View, Calif.: Mayfield, 1998. A wide ranging selection of topics and essays.
Beauchamp, Tom L. and James F. Childress. Principles of Biomedical Ethics. 4th ed. New York: Oxford University Press, 1994. Analysis, defense, and applications of principles of autonomy, non-maleficence, beneficence, and justice.
Brody, Howard. Stories of Sickness. New Haven, CT: Yale University Press, 1987. Recasting of ethical issues in terms of patients' narratives of illness and dialogues with doctors.
Buchanan, Allen E. and Dan W. Brock. Deciding for Others: The Ethics of Surrogate Decision Making. Cambridge: Cambridge University Press, 1989. A general theory for treatment decisions for incompetent patients, especially minors, the elderly, and psychiatric patients.
Callahan, Daniel. Setting Limits: Medical Goals in an Aging Society. New York: Simon & Schuster, 1987. A life-stage account of appropriate health care and technological restraint, further developed in What Kind of Life. New York: Simon & Schuster, 1990.
Daniels, Norman. Just Health Care. New York: Oxford University Press, 1985. Distribution of health care resources to maintain age-relative equal opportunity, extended for geriatric policy in Am I My Parents Keeper? New York: Oxford University Press 1988.
Engelhardt, H. Tristram, Jr. The Foundations of Bioethics, 2nd edition. New York: Oxford University Press, 1996. Libertarian social analysis of autonomy and rights to abortion, infanticide, healthcare, treatment refusals.
Gillon, Raanon and Ann Lloyd, eds. Principles of Health Care Ethics. Baltimore: John Wiley & Sons, 1994. Criticisms and defenses of the canonical medical ethics principles of autonomy, beneficence, non-maleficence, and justice.
Holmes, Helen Bequaert and Laura M. Purdy, eds. Feminist Perspectives in Medical Ethics. Bloomington: Indiana University Press, 1992. Essays from Hypatia on ethics of care and related issues.
Kamm, F(rances) M(yrna). Morality, Mortality. 2 vols. New York: Oxford University Press, 1993, 1996. A bioethical treatise with detailed deontological analyses of euthanasia and allocation of scare organs for transplant.
Nelson, Hilde Lindemann and James Lindemann Nelson. The Patient in the Family. New York: Routledge 1995. A defense of family participation and interests in therapeutic decisions.
Pellegrino, Edmund D. and David C. Thomasma. The Virtues in Medical Practice. New York Oxford University Press, 1993. An extension of Aristotelian and Scholastic analyses of virtue to physicians.
Pence, Gregory. Classic Cases in Medical Ethics. 2nd ed. New York: McGraw-Hill, 1995. Detailed accounts of widely publicized cases, studies, and policies.
Percival, Thomas. Percivals Medical Ethics. Chauncy D. Leake, ed. Huntington, NY: Robert E. Krieger Publishing, 1975. An English hospital code adapted by the American Medical Association in 1847, and much revised thereafter.
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Washington, D.C.: U.S. Government Printing Office. See especially the following reports: Making Health Care Decisions (vols. 1, 3, 1982); Protecting Human Subjects (1981); Implementing Human Research Regulations (1983); Securing Access to Health Care (vols. 1,2, 1983); Deciding to Forgo Life-Sustaining Treatment (1983).
Rachels, James. The End of Life: Euthanasia and Morality. Oxford: Oxford University Press 1986. A defense of euthanasia, active and passive, when "biographical life" is over.
Reich, Warren T., ed. Encyclopedia of Bioethics, 2nd ed. New York: Macmillan, 1995. 5 vols. A comprehensive source (437 contributors; 464 articles).
Veatch, Robert M. ed. Medical Ethics. 2nd ed. Sudbury, Mass.: Jones and Bartlett, 1997. Surveys of fourteen major topics (including AIDS, National Health-care Reform, Psychiatry) by American bioethicists.
Principal journals include:
Cambridge Quarterly of Health Care Ethics
Hastings Center Report
IRB: A Review of Human Subjects Research
Journal of Clinical Ethics
Journal of Medical Ethics
Journal of Medicine and Philosophy
Kennedy Institute of Ethics Journal with "Scope Notes" (annotated bibliographies on specific topics)
Law, Medicine & Health Care.
The Kennedy Institute also publishes a bimonthly New Titles in Bioethics and revises monthly Bioethicsline, a bibliographic data base in the MEDLARS system.
Relevant articles occur occasionally in Ethics; Journal of the American Medical Association; Philosophy & Public Affairs; Milbank Quarterly; New England Journal of Medicine, Theoretical Medicine.