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Paper presented at an ethics training program for family physicians at the Riyadh Castle Hotel on 20th March 2010 by Professor Omar Hasan Kasule MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Department of Bioethics Faculty of Medicine KFMC omarkasule@yahoo.com
1.0 SCOPE OF MEDICAL ETHICS[1]
1.1 Theories, principles, and methodology
- Ethical theories: liberalism, communitarianism, deontology, Kantian ethics, Feminist theories, Virtue, Moral relativism
- Ethical principles: autonomy, beneficence, nonmalefacence, and justice
- Methodological approaches to ethical analysis: casuistical reasoning, narrative ethics, empirical approaches to ethics, thought experiments, deliberative ethics, medical humanities, law and ethics, reflective equilibrium,
- Other considerations: hermeneutics, paternalism, rights, needs, doctrine of double effect, acts and omissions, ordinary and extra ordinary means, personhood and moral status, commodification.
1.2 Ethical issues in clinical practice
- Issues of consent: informed consent, decisions for the incapacitous/incompetent, consent for children,
- Issues of confidentiality and disclosure: disclosure of surgical risk, confidentiality, truth telling
- Physician’s dilemmas: conscience, dual responsibilities
- Start of life issues: abortion, maternal-fetal conflict,
- Reproduction: contraception, genetics
- Disabilities:
- Psychiatric issues: compulsory treatment, intellectual disability
- Geriatric issues:
- End of life issues: organ transplantation, euthanasia, life support
1.3 Ethics in public health:
- Concepts: health, illness, health promotion, disease prevention
- Health economics: priority setting, decisions, equity,
- Ethical issues: vaccination, screening, epidemiology, infectious disease, drug addiction, smoking, disaster relief, refugee problems
1.4 Research ethics
- Animal research
- Governance of research
- Informed consent
- The pharmaceutical industry
- Publishing
- Cloning and stem cell research
- Genetic research
2.0 DEFINITION and CLASSIFICATION
2.1 DEFINITION OF ETHICS
Ethics is the philosophy of morality. It is a discipline of study concerned with distinguishing the moral from the immoral and the right from the wrong. Ethics is defined as various ways of understanding and examining the moral life. The approach to a moral problem in medicine is determined by the background culture, philosophy of life and worldview.
Ethics as a discipline is not a corpus of knowledge or facts. It is principles and methodology used to analyze specific situations in order to make moral judgments. Ethics is not a theoretical discipline. It is needed in daily life because humans as individuals and as communities have to make decisions that involve moral judgments.
2.2 CLASSIFICATION OF ETHICS
Normative ethics: The normative is what ought to be done. Normative ethics is concerned with criteria and standards of defining what is moral and what is otherwise. These criteria can be found explicitly stated in the revelations or can be derived by logical reasoning from basic principles in the revelations. Normative ethics based purely on human reasoning without the guidance of revelation is subject to human bias,
Non-normative ethics: Non-normative ethics is what most people do. Non-normative ethics tries to establish factually what the actual situation is. Non-normative ethics is a description of what is going on. It may also be related to language, concepts, methods, and meanings.
Applied ethics: It seeks to find practical solutions to actual problems without necessarily theoretical considerations. Applied ethics deals with application of moral or ethical principles to solving actual practical problems. Usually there are 2 or more alternative solutions to a problem. Selection of the right solutions requires moral judgment. Such issues are usually controversial and material arguments backed by empirical data can be made for each solution. Examples of such issues are: equality (racial, gender, economic), the environment (economic development versus pollution, over-population), war and peace, abortion, euthanasia, withdrawing artificial life support, prenatal diagnosis, frozen embryos, animal research, screening for HIV, disposal of waste products, genetic engineering, autonomy, confidentiality, allocation of health resources etc.
Bioethics, a branch of applied ethics, is a discipline that deals with ethical implications of medical research and medical interventions.
Comparative ethics: Comparative ethics, also called descriptive ethics, is concerned with empirical description and comparison of moral beliefs and practices of different communities and to understand underlying causative factors. Comparative ethics discovers what is common and what is different among different communities. These differences and similarities may be related to physical factors (the environment), belief systems, and culture, contemporary or historical experiences. Study of many societies reveals that there is unanimity on a core of moral issues. For example all societies agree that murder and theft are immoral. There are however some issues on which there is no unanimity regarding their morality either between different communities or in the same community at different historical epochs.
3.0 HISTORICAL BACKGROUND
3.1 The rise of secular European bioethics
Ethics have been part of medicine from the beginning. Some statements in the Hippocratic Oath deal with professional medical ethics. It is divided into two parts. The first part is on duties of physicians to students of medicine as well as the duties of the pupil to the teacher. The second part covered prescription of only beneficial treatments, refraining from causing harm or hurt, and to live exemplary personal and professional life.
Concern with ethics in the past was not as intensive as it is at the moment. It was assumed that physicians would be ethical and moral in their work and this was true to a large extent because religiosity was a leading characteristic of life in the past.
Towards the last quarter of the 20th century ethical considerations became a major concern for two reasons. The first reason is that developments in medical technology gave rise to problems such as life-support, in-vitro fertilization and others that had moral dimensions. The second reason was the increase in moral violations by medical practitioners.
The medical profession found itself in a dilemma because moral values were not part of the secular medical curriculum. Secularism gradually encroached on civil life starting with the 16th century renaissance. By the 20th century, all aspects of European life including medicine had become secularized. The practical manifestation of this secularization was the marginalization of religious and moral values and confining them to the private arena of individual’s belief. When medical problems that required moral solutions arose, the medical profession and society at large were not ready to face the challenges. The positive secular laws that existed were deficient in resolving moral problems. It became necessary to develop secular medical ethics as a new discipline to deal with the challenges.
Muslims did not face a similar dilemma because they kept their divine Law, shari’at, intact. Islamic Law, unlike European secular law, is based on a complete system of morality and can therefore handle all moral problems that arise in medicine from a legal perspective. It also is very flexible being adaptable to many new and novel situations. Strictly speaking Muslims do not need to talk of ethics as a separate discipline because it is already included in their Law.
3.2 Main landmarks in the development of European secular bioethics
The Hastings Center in New York George Washington University in Washington DC
4.0 EUROPEAN ETHICAL THEORIES
4.1 Definition of an ethical theory: An ethical theory provides a framework within which moral reasoning and judgment can be undertaken. Moral judgment is basically reaching a consensus about what is right or wrong. There is no one coherent European theory of ethics because of the historical background.
4.2 Eight ethical theories: According to Beauchamp and Childress (1994) there are eight ethical theories. None of them can on its own explain all ethical or moral dilemmas. A good ethical theory must be clear, coherent, complete, comprehensive, simple, practicable, and able to explain and justify. None of these 8 theories has all these characteristics. In practice more than one theory may have to be combined to solve a specific ethical issue.
4.3 Consequence-based theory: According to the utilitarian consequence-based theory, an act is judged as good or bad according to the balance of its good and bad consequences. Utilitarianism means attaining the greatest positive with the least negative. This theory has a problem in that it can permit acts that are clearly immoral on the basis of utility.
4.4 The obligation-based theory is based on Kantian philosophy. Immanuel Kant (1724-1804) argued that morality was based on pure reasoning. He rejected tradition, intuition, conscience, or emotions as sources of moral judgment. A morally valid reason justifies action. Acts are based on moral obligations. The problem with the Kantian theory is that it has no solution for conflicting obligations because it considers moral rules as absolute.
4.5 The rights-based theory is based on respect for human rights of property, life, liberty, and expression. The individual is considered to have a private area in which he is master of his own destiny. Rights may be absolute or relative. A positive right is one that has to be provided to the individual. A negative right is one that assures prevention of or protection from harm. There is a complex inter-relation between rights and obligations. Individual rights may conflict with communal rights. The problem of the rights-based theory is that emphasis on individual rights creates an adversarial atmosphere.
4.6 Community based theory: According to the community-based theory, ethical judgments are controlled by community values that include considerations of the common good, social goals, and tradition. This theory repudiates the rights-based theory that is based on individualism. The problem with this theory is that it is difficult to reach a consensus on what constitutes a community value in today’s complex and diverse society.
4.7 The relation-based theory gives emphasis to family relations and the special physician-patient relation. For example a moral judgment may be based on the consideration that nothing should be done to disrupt the normal functioning of the family unit. The problem of this theory is that it is difficult to deal with and analyze emotional and psychological factors that are involved in relationships.
4.8 The case-based theory is practical decision-making on each case as it arises. It does have fixed philosophical prior assumptions.
5.0 EUROPEAN ETHICAL PRINCIPLES
5.1 Sources of ethical principles: Europeans consider the Hippocratic oath as the starting point of ethical reasoning. This is supplemented by views of European philosophers and thinkers to develop ethical theories that are in turn used to solve practical problems.
5.2 Definition of ethical principles: Ethical principles are axioms that simplify ethical reasoning. They have to be specific. In practice one principle may have to be balanced against another one. In some cases one principle may override another. There are 4 basic European ethical principles according to Beauchamp and Childress (1994)
5.3 The Principle of Autonomy is the power of the patient to decide on medical procedures.
5.4 The Principle of Non-malefacence is avoiding causation of harm.
5.5 The Principle of Beneficence is the providing benefits and balancing them against risks and costs.
5.6 The principle of justice is distribution of benefits, costs, and risks fairly. Application of the above principles requires ethical rules.
6.0 EUROPEAN ETHICAL RULES
6.1 Classification of ethical rules: The European ethical rules may be substantive, authority, and procedural rules.
6.2 The substantive rules deal with veracity, confidentiality, privacy, and fidelity.
6.3 The authority rules deal with surrogacy, professional authority, and rationing.