These are some notes I did for a local MSc course in Haematology - they are by no means exhaustive, dears, but I hope they may be useful for you.
Medical Ethics
Introduction to Issues in Medical Ethics
From the earliest emergence of a medical profession as we understand the term in Western countries, people who practised medicine have recognised their power over the people whom they treat, and have displayed an acute awareness of the responsibility and accountability which went with it.
The Hippocratic Oath
This responsibility and accountability found expression in the Hippocratic Oath, which until very recently, was taken by all people wishing to practice medicine upon their graduation.
Hippocratic Oath -- Classical Version
I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my
witnesses, that I will fulfil according to my ability and judgment this oath and this covenant:
To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of
money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art -
if they desire to learn it - without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my
sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according
to the medical law, but no one else.
I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and
injustice.
I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a
woman an abortive remedy. In purity and holiness I will guard my life and my art.
I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.
Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in
particular of sexual relations with both female and male persons, be they free or slaves.
What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no
account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.
If I fulfil this oath and do not violate it, may it be granted to me to enjoy life and art, being honoured with fame among all men for
all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.
Translation from the Greek by Ludwig Edelstein. From The Hippocratic Oath: Text, Translation, and Interpretation, by Ludwig
Edelstein. Baltimore: Johns Hopkins Press, 1943.
We can make the following observations:
Firstly, the practitioner had a responsibility to the patient to protect them from harm or injustice. This included the administration of a drug which would kill the patient, even if the patient themselves requested it. Secondly, the unborn were accorded the protected status of a human being. A doctor swore not to perform an abortion on a woman. The doctor was not permitted to use his (and of course, it was widely accepted that practitioners would be men) position of power and authority to take advantage of patients and their households, either sexually or because of information gleaned in the course of treatment. The confidence of the patient and their household should be inviolate.
However, the very first words of the Hippocratic Oath set out the terms of reference under which it was taken, that is, the oath was made before deities and divinities by whom the practitioner would be held accountable for the keeping or breaking of the oath. We should not be surprised at this. Many practitioners of medicine were also priests attached to temples, particularly temples of Apollo and his twin sister Artemis. In Ephesus, friezes depict the arts of the priest/doctor who would prescribe herbal remedies, ointments and unguents, and even, in one frieze, performs brain surgery upon those who are sick.
The importance of this clause of the Oath, however, is that ultimately, the practitioner saw the authority under which he worked as a divine authority, with the right to define certain practices as acceptable or unacceptable to that authority. This may have been an acknowledgement that life ultimately derived from a divine source of creation. It certainly appears to recognise a source of understanding for what was right and wrong that derived from an authority beyond human authority, and accountability to it.
The clear assumption is that human life is inviolate, in that the physician does not have the right to compromise it in any way – to make such a judgement is beyond his power.
The traditional principles governing the view of human life in Western countries
The terms of the Hippocratic Oath were largely unquestioned within Western Medicine until recently. Thus, the Pope could say,
"Until quite recently, medical ethics in general and Catholic morality were rarely in disagreement. Without problems of conscience, Catholic doctors could generally offer patients all that medical science afforded."
Pope John Paul II "Address of John Paul II on the Occasion of the International Congress of Catholic Obstetricians and Gynecologists." June 18, 2001.
This statement demonstrates the close similarity between Judaeo-Christian ways of understanding human life and the principles reflected in the Classical Hippocratic Oath. A consideration of Judaeo-Christian principles is key to understanding the current debates raging over certain medical practices and increased technological capacities.
The Sanctity of Human Life
This expression places human existence firmly within the sphere of religious language. The word ‘sanctity’ derives from ‘sacred’, and implies something set apart from other things, perhaps things of a similar order. Traditionally this expression has been used only of human life, for Jews, Christians and Muslims believe that human life is of a different order to that of other animal life. These monotheistic religions teach that the world does not exist by accident, but by the express purpose of a Divine Creator. The essential difference between humans and other animate life forms, for them, lies in the special relationship which exists between humans and their Creator. This difference is expressed succinctly in Genesis 1:26. "Let us make man in Our own image." In some way, then, the quality of human life reflects that of a Divine Creator, and although all life belongs to God, nevertheless, human life is special and precious to God in ways that animal life is not. Jesus of Nazareth expressed this view when he said, "Aren’t sparrows sold five for a penny in the market - yet your Heavenly Father knows when each one of them dies. You, however, are worth more than many sparrows."
The importance of human life to its Creator is developed in both the Jewish Bible (Old Testament) and the Christian New Testament. God forbids the deliberate taking of another human life in the 10 Commandments – "Thou shalt not murder". The creative foreknowledge and purpose of each human life is implicit in Psalm 139 "You knit me together in my mother’s womb… I am fearfully and wonderfully made … and my soul knoweth it right well!" Jeremiah the prophet is told by God that "before you were in the womb I knew you and called you …." And of course, the name and purpose of Jesus is announced to his mother before conception. "You shall conceive in your womb and bear a Son, and you shall call his name Jesus, for he will save his people from their sins." Each human being is known by the mind of the Creator even before birth.
The human body is special too. The incarnation of Jesus has, for Christians, sanctified everything about being human. Birth, life and death are crucial. What we do with, for and to our bodies is important. Paul, arguably the greatest of Christian teachers, wrote to a church in ancient Corinth that "The body is the temple of the Holy Spirit." He went on to argue that whoever harmed the body was therefore harming God’s temple, and would be held responsible for it.
Traditionally, then, the Christian response to medical issues has been to ‘Love God’ by recognising that in everything we do with our own life and that of other people, we are accountable to Him, and to ‘Love our neighbour’ by doing all we can, within a God-given framework, to promote the health and well being of others, and to treat and comfort those who are sick and dying, bringing healing and wholeness where possible and every comfort when healing is not possible.
This response is clearly visible in the role that Christians both as part of institutions and individually, have played in the care of the sick, the young, the old and the dying. The earliest hospitals in this country are named after saints precisely because so many of them had religious foundations. Christians, Jews and Muslims have been notable for the number of vocations to the practice of medicine in all its forms, which their faith has inspired.
The key issue was human accountability to a life-giving Deity who jealously guarded the rights of all to life, required humans to care for the sick, helpless and vulnerable and condemned the exploitation of the weak by the strong as an affront to human dignity and to the loving Creator who made humans. The point is made by Pope John Paul II who wrote
: "Whatever is opposed to life itself, such as any type of murder, genocide, abortion, euthanasia, or wilful self-destruction, whatever violates the integrity of the human person, such as mutilation, torments inflicted on body or mind, attempts to coerce the will itself; whatever insults human dignity, such as subhuman living conditions, arbitrary imprisonment, deportation, slavery, prostitution, the selling of women and children; as well as disgraceful working conditions, where people are treated as mere instruments of gain rather than as free and responsible persons; all these things and others like them are infamies indeed. They poison human society, and they do more harm to those who practise them than to those who suffer from the injury. Moreover, they are a supreme dishonour to the Creator".
From "Evangelium Vitae" Papal encyclical 1995
More recent ethical systems – as they have been applied to medicine
Whilst Christianity still forms a vital background by which the ethical principles of the majority of people in Western countries are informed, there has been a marked decline in adherence to any organised religious faith, and increasingly, other systems of ethical thought have taken their place on the stage of medical thinking and opinion-forming.
We might define ethics as systems of arriving at decisions about what makes a course of action right or wrong. Advances in modern technology have meant that the answers to questions like "Can we do such and such .." have increasingly been "Yes" or "Not yet, but in five years’ time …"
Ethics attempts to provide the framework by which we could answer questions like "Should we do this?" or "Ought we to do that?"
A comparison of ethical systems of answering such questions becomes very important. What follows is not intended to be an exhaustive examination of such systems, but gives broad brushstrokes by which they can been recognised.
Consequentialism
Under such systems of ethics, an action is judged as right or wrong by its outcome or consequence.
A desirable outcome might be increased happiness or satisfaction for the individual (hedonism), measurable perhaps in lack of pain, or in the removal of obstacles.
Under such a system, an abortion might be justifiable if it would remove from, say a 16 year old girl, the prospect of having to care for and nurture a child at the expense of her education, and, arguably, her future prosperity.
Utilitarianism as propounded by Bentham or J S Mill might define a moral action as that which brings the greatest happiness to the greatest number.
Bentham might argue that compelling people to have their babies vaccinated using the MMR vaccine, would be morally preferable than leaving such a decision to the discretion of parents because it would drastically reduce the incidence of measles, mumps and rubella (and their horrible consequences) within the population at large. The conflicting claims of parents who fear that the vaccination could produce autism in some (and possibly their children), and those who insist that parents should have the final say in whatever medical treatment is offered to their children might be considered secondary to the total happiness produced by having a low (and decreasing) incidence of these childhood diseases.
The problems with consequentialist ethics lie in the ability accurately to predict what the outcomes of decisions will be in the long term. The 16-year-old aborting her unborn child may certainly gain some initial relief, but she may experience long-term physical and psychological effects of abortion which could devastate her life many years on. Likewise, the results of removing from parents the rights and responsibilities of managing their children’s health may open a door of state interference in the relationship between parents and children which may later be viewed as extremely sinister.
Situation ethics has gradually become many people’s answer to the moral problems they encounter, even if they don’t recognise it. Most of us will recognise the statement "You can’t lay down rules for this sort of thing. You have to judge every situation differently on its merits." People will commonly use this sort of ethical principle to judge whether or not someone should have an abortion, or whether an unconscious person’s life support system should be turned off, or whether a person should be told that they have a terminal illness and a limited life expectancy.
It rests on the idea that ‘hard and fast’ rules of behaviour can be helpful tools, but poor masters. That as situations differ in so many respects, then so should our response. Classical Situation Ethics as put forward by Joseph Fletcher encouraged people to use the ‘love’ principle – what would be the most ‘loving’ thing to do in the circumstances?
The virtue of this system is that it permits for flexibility in an area where there are almost infinite permutations of circumstances, and where one response for one person may seem completely inappropriate as a response for another.
The problem is, how can we be certain that our response will, in the long run, turn out to be the most loving? There may be circumstances which have led to these situations which need careful investigating and information not available to those who lave to respond lovingly. Also, where there are two people involved in a situation, whose interests conflict, how should we decide whom ‘to love’?
Finally, as David Stone says,
" In addition, no one has successfully demonstrated that the principle of love really should be allowed to exercise a right of veto over everything else, including, for example, the principle of justice."
Emotivism
This school of thought, which includes existentialism and logical positivism proposes that ‘moral’ statements are no more or less than expressions of opinion on the part of the speaker. The only statements that have meaning are those that are measurable, observable or quantifiable. Thus a statement like "Stealing is wrong." (or even "All property is theft.") have no measurable or objective basis. Such statements are therefore ultimately meaningless.
This view would remove many ethical obstacles to certain medical procedures which cause others angst. Where there is no objective right or wrong, only statements of opinion, there can be no obstacle to any form of treatment which could produce the desired effect.
The problem is, that although we might choose to perceive other people’s moral statements as expressions of opinion, we are at the same time inclined to view our own as having very considerable weight. E.g. "It’s not fair!" Furthermore, how many people really feel that "It just felt like the right thing to do." Would be an adequate response to the question "Why did you kill him?" We would expect an adequate response to such a question to employ reason, not simply emotional response.
Deontology (Duty-based ethics)
This system of ethics proposes that there are higher sources of authority not dependent upon human reason, but to which humans are subject. Demands would be phrased in statements such as ‘You ought to do/not to do X.’ or ‘You should (not) do Y.’ There are no conditions attached to such demands and they are absolute and are to be obeyed regardless of consequences.
The Categorical Imperative
This type of demand is often known as ‘a categorical imperative’, and is most often associated with Immanuel Kant. He believed that duty was the highest calling, and that we should do what we perceived to be our duty regardless of the consequences, not least because he said that too often there was not enough evidence or information available to us reliably to determine the total outcomes of our actions.
He suggested that one other factor had to be excluded from dutiful decision-making. Taking an action because you will benefit from it means that it cannot be a moral action. Kant also rejected acting on an external moral authority when in conflicted with your personal moral conviction. Such unthinking obedience is not a moral position. There must always be the personal conviction that the action is right.
Kant’s teaching on the guidelines for a ‘moral’ action can be broken down roughly into two themes:
Kant never attempts to prescribe the content of a moral position, but to provide the framework for making that decision.
For example, a consultant has received information from a series of tests she has carried out on a patient which suggest that the patient has a terminal disease and has only a few weeks to live. The consultant has to decide whether to accede to the wishes of the patient’s family and lie about the condition to the patient so that the patient has no idea that their life will shortly end.
Kant would argue that lying in this situation is only permissibly if one can accept that lying should be universally acceptable in all situations. If the consultant could not accept that lying should be a ‘universal law’ then she would not be justified in lying in this situation.
However, consider another scenario. A member of the opposition to an oppressive political regime has taken shelter in the house of a friend. The secret police come to the door and ask the friend whether the politician is in the house. What should the friend do? One may, in this case, not choose to look at the principle of telling the truth as the universal law, but focus instead of the preservation of innocent life. Thus the universal law in play here might be that anything necessary to prevent the taking of innocent life is a correct action.
Note that under this theory, there are no prescribed ‘moral’ actions, only ways of defining moral actions. Furthermore, for Kant, the decisive factor in whether or not an action was moral was the personal conviction of the one who had to take the action. Thus it is entirely possible that people could conscientiously arrive at totally opposite choices of action in the same situation, depending on all sorts of outside factors, like upbringing, personal experience, culture etc.
Religious guidance
Religions actively propose a theory of explicit guidance from a Divine Being, usually mediated through sacred writings, like the Qur’an, Bible or Guru Granth Sahib, or from a religious authority which interprets the revealed will of the Divine Being, such as the Magisterium of the Roman Catholic Church, an ayatollah or guru.
People of faith believe that a superhuman moral being, God, makes demands upon humans as to how they regard Him (or Her) and how they respond to His demands in the way that they treat other people. The Divine Being is the source of morality and reveals what is right or wrong through the Book or the interpreters(s).
One problem with this method of determining medical ethics is that many situations and questions that face us today simply were not around when religious documents were being written. People simply did not have to consider the morality of genetic engineering or IVF treatment for example. Neither were people kept alive on Life Support Machines, thus creating the dilemma of if and when to turn them off.
Furthermore, even if a faith group recognises a common source of authority, they may not always agree when considering what that source of authority has to say about a particular issue. Christians may accept the authority of the Bible as a collection of writing inspired by God. But when using it to assist them come to a conclusion about, say, whether or not contraception is morally acceptable as a practice for Christians, opinions may differ between groups.
Another problem arises when people of faith encounter others who do not share their particular views. Whilst there may well be common ground between people on the correct course of action to take in a particular circumstance, the variance between the world view of people of faith and people of no faith will eventually lead to deep division and possibly deep resentment as each group feels the other to encroach upon its own world view.
Responses to the changing ethical world view from the Medical Profession
America and Europe continue to play a key role in the world of medicine. American and European society and thought has been deeply influenced by secular (non-religious) humanism. Humanism is a world view which has at its centre human beings, and their wants and desires. Many people who would call themselves Humanists are atheist (they believe there is no God), and those who are agnostic (are undecided whether or not there is a God) often believe that the existence (or otherwise) of God is an irrelevance to the day to day happiness of humanity.
Although recent surveys (1999) suggest that in Britain, for example, 70% of people believe that there is a God, nevertheless only about 8% attend a place of worship regularly. Effectively, then, British society is a secular (non-religious) society. This is true of the majority of countries in western Europe, although not so true in America where well over half the population attends a place of worship regularly and would claim to be adherents of a world faith, mainly Christianity.
However, in response to the increasing secularization of society, the medical profession has reviewed the wording of the oaths which all medical practitioners are required to take upon graduation.
For example, below is the Physicians oath (Declaration of Geneva 1948) adopted by the General Assembly of the World Medical Association in September 1948 and amended by the World Medical Assembly in Sydney in 1968.
At the time of being admitted as a member of the medical profession:
This oath appears to be a response to the atrocities committed by doctors in Nazi Germany who used their considerable skills to engage in research which horribly violated unwilling human subjects.
The similarities to the classical Hippocratic Oath are clear. However, the references which indicate a responsibility to a divine authority to which practitioners are responsible and answerable has been removed, and replaced with a promise to ‘consecrate my life to the service of humanity.’ The prime duty of the practitioner, above all considerations, including religion, is to ‘my patient’.
Many medical schools in America use a modern version of the Hippocratic Oath devised in 1964 by the wonderfully named Louis Lasagna, then Academic Dean of the School of Medicine at Tufts University:
Hippocratic Oath -- Modern Version
I swear to fulfill, to the best of my ability and judgment, this covenant:
I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine
with those who are to follow.
I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic
nihilism.
I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the
surgeon's knife or the chemist's drug.
I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a
patient's recovery.
I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must
I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take
a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not
play at God.
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the
person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.
I will prevent disease whenever I can, for prevention is preferable to cure.
I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind
and body as well as the infirm.
If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always
act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.
Again, this modern version of the Hippocratic Oath contains no reference to accountability to a divine being, placing the needs of
the patient as a person and membership of society at the centre of the obligations of the practitioner.
The implications of these developments are quite profound, for they have led to deep and divisive debate within the medical profession, those engaged in medical research especially genetic research and embryology and this debate has spilled over into society at large, as more and more technical barriers to obtaining information and effecting desired results are scaled and breached.
The debate centres on the question "Do humans ‘own’ human life or are they answerable to a Creator?" Despite the increasing secularisation of European and to a lesser extent, American society, Christianity informs the moral and ethical sense of a large proportion of the population – so that the expression "playing God" is widely understood as a pejorative term describing the actions of scientists who are trying to alter the natural order in ways that are considered unacceptable.
From this initial question, others can be asked. If humans are indeed answerable to a creator, then what demands, exactly does that creator make of them, and which authorities are competent to convey that information to the world of medicine. For example, does a creator permit women to have full determination of their own fertility even if it means that conception is artificially prevented, or unborn human beings destroyed in the process?
If we are answerable not to a divine being but to society, who, within a society has the competence to determine what the expression ‘respect for human life’ might mean in, say the field of embryo research or genetic modification for therapeutic purposes?
These questions have profound and increasing resonance as human technical competence increases. In the second part of this series, we shall consider the implications in respect of some recent high profile cases.