Preface
The field
of medicine is one in which ethical behavior is paramount. It is
a life of service, and throughout her/his career every
physician will constantly face new ethical challenges. This course
is intended to give physicians a deeper understanding of medical ethics
and tools to address the ethical questions one encounters. It consists
of background information on medical ethics, a model for making ethical
decisions, an in-depth discussion of a number of contemporary issues
requiring decisions based on medical ethics and materials for acquiring
CME credits.
Background
Since the first code of medical ethics was published in the United
States—by the American Medical Association
in 1847—literally millions of words have been written on the subject.
In fact, in a recent internet search of “United States Code of Medical
Ethics” the search engine showed 22,400,000 results. There are state
and federal codes, professional association codes, organization codes
and church-affiliated codes. There are also international codes. In
short, there is an overwhelming body of work on this topic, much of
which is specific to a very small segment of medical practitioners.
Ethics
vs. Laws
Ethics should not be confused with laws. A code of ethics
is based on morality and standards rather than legislation.
Black’s Law Dictionary offers the following definition of ethics:
What is generally called the ethics of the profession is but a consensus of expert opinion as to the necessity of professional standards.
The Hippocratic Oath concerns ethical behavior. This behavior was considered so sacred, the oath was sworn to the god Apollo, the physician, and it states in part:
I will follow that system of regimen which, according to my ability and my judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.
The Code of Hammurabi, on the other hand, is a strict set of laws governing how much a physician will earn for his efforts, and what will happen if he fails. For example:
LAW #215: If a physician make a large incision with an operating knife and cure it, or if he open a tumor (over the eye) with an operating knife, and saves the eye, he shall receive ten shekels in money.
LAW #218: If a physician make a large incision with the operating knife, and kill him, or open a tumor with the operating knife, and cut out the eye, his hands shall be cut off.
It is fairly clear why elements of the Hippocratic Oath survived and Hammurabi’s laws didn’t.
The Evolution
of Medical Ethics
When the AMA published its first Code of Ethics
it was primarily concerned with
etiquette—how the physician should conduct her/himself toward the patient, and
how the patient and the community as a whole should conduct themselves toward
the physician.
Respecting a patient’s confidentiality was of extreme importance in this first code, and expressed very strongly in chapter one:
Secrecy and delicacy, when required by peculiar circumstances, should be strictly observed; and the familiar and confidential intercourse to which physicians are admitted in their professional visits, should be used with discretion, and with the most scrupulous regard to fidelity and honor…The force and necessity of this obligation are indeed so great, that professional men, have under certain circumstances, been protected in their observance of secrecy, by courts of justice.
Ethical
Challenges in Medical Treatment
The
first real challenge to the AMA Code occurred more than fifty years
later
at
the turn of the century and with the highly revered
issue of confidentiality. At that time syphilis was rampant in
the United States. Conservative estimates
are that it affected ten to fifteen percent of
the general population, but exact figures are unknown because there
was
no system of public reporting. It was also
a tremendous stigma because it was believed that
only persons of the lowest moral character contracted the disease,
so people
who had it didn’t reveal it to anyone. It was such a moral taboo that it was
never written about or discussed so it was a disease totally shrouded in secrecy.
Syphilis represented a huge ethical challenge to physicians on a number of levels. At that time physicians had much greater latitude in dealing with patients and how much information a patient could/should have, which greatly affected the decisions they faced. For example,
Should a patient even be told of a suspected diagnosis—since there was no cure—or should it be ignored until it had reached an advanced stage where there was no doubt?
Should a physician intervene if a patient with syphilis wants to get married and not tell her/his potential spouse?
Should persons infected be segregated from the general population?
Should physicians even try to find a cure, since that might encourage immoral behavior?
To help physicians deal with these difficult questions, in 1903 the AMA revised their code and changed the name to “Principles of Medical Ethics.” The Principles were refined again in 1912.
One of the primary changes from the Code to the Principles dealt directly with the issue of confidentiality, as demonstrated by the revisions made to the section on secrecy previously quoted. In the 1912 Principles, the section read:
Patience and delicacy should characterize all the acts of a physician. The confidences concerning individual or domestic life entrusted by a patient to a physician and the defects of disposition or flaws of character observed in patients during medical attendance should be held as a trust and should never be revealed except when imperatively required by the laws of the state.
There are occasions, however, when a physician must determine whether or not his duty to society requires him to take definite action to protect a healthy individual from becoming infected because the physician has knowledge, obtained through the confidences entrusted to him as a physician, of a communicable disease to which the healthy individual is about to be exposed. In such a case, the physician should act as she/he would desire another to act toward one of his own family under like circumstances. Before she/he determines his course, the physician should know the civil law of his commonwealth concerning privileged communications.
The AMA Code of Ethics has continued to evolve and has been joined by codes of ethics created by almost every profession in health care, as well as many other physician organizations. A copy of the Preamble to The Code of Ethics of the AMA is Appendix A, and The American Osteopathic Association (AOA) is Appendix B.
Ethical
Challenges in Medical Research
After World War II ended,
and the atrocities committed
by the Nazis became known, many of the nations
of the world joined together
to create the first “universal” Code of Ethics to
govern the practice of medicine. It is the “Declaration
of Geneva,” which was
adopted by the General Assembly of the World
Medical Association at a meeting in Geneva,
Switzerland in 1948. The declaration, a copy
of which is included
as Appendix C, begins with the following
statement:
At the time of being admitted as a member of the medical profession: I solemnly pledge myself to consecrate my life to the service of humanity.
There were rapid advances made in medical research in the post-World War II period, especially in the area of infectious diseases. There were global rumors of vaccines being tested on people before they had been adequately tested on animals, or being tested on uninformed subjects, or on subjects who had not been completely informed of all the risks of the research. In order to create protections against this behavior, in 1964 the World Medical Association adopted the “Declaration of Helsinki,” which has been updated many times over the last decades, most recently in 2004. In its introduction, the Declaration states in part:
Medical progress is based on research which ultimately must rest in part on experimentation involving human subjects. In the field of biomedical research a fundamental distinction must be recognised between medical research in which the aim is essentially diagnostic or therapeutic for a patient, and medical research the essential object of which is purely scientific and without implying direct diagnostic or therapeutic value to the person subjected to the research.
