Abstract
The power and prestige of modern medicine impose a special obligation on medical professionals to practice their art in a morally responsible way. Ethical theories, ancient and modern, address the basis of morality and offer guidance for decision-making. This chapter focuses on consequentialist and deontological theories of ethics in their application to the practice of medicine. The discussion includes the (relatively recent) rise of the specialized field of “applied bio-medical ethics.” In this context we consider the effort to condense the insights of ethical theories to concisely stated “principles” which can be used as analytical tools for decision making.
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Notes
- 1.
It is unclear how much of the Hippocratic Corpus can be attributed directly to Hippocrates himself, and how much of it stems from his later students and followers.
- 2.
A few women physicians are mentioned in the surviving documents from ancient Greece and Rome, but the medical profession at the time was almost entirely a male preserve.
- 3.
These issues are addressed specifically in Chaps. 13, 18 and 8 of this volume – “Informed Consent in Fetal Hypoplastic Left Heart Syndrome,” “Between Death and Donation: Ethical Considerations in Pediatric Heart Transplantation,’’ and ‘‘Ethical Issues Surrounding the use of Post Cardiotomy ECMO” (respectively).
- 4.
Though some authors draw a distinction between the uses of the terms “ethical” and “moral,” there is no agreed-upon way of making this distinction, and the attempt is often more confusing than helpful. The two will be used interchangeably in this chapter.
- 5.
Chapter 2 of this volume – entitled “Autonomy and the Principles of Medical Practice” – makes productive use of the ancient conception of virtue.
- 6.
“Hedon” is derived from the Greek word for pleasure; “dolor” from the Latin term for pain. This quantification procedure, often derided nowadays, is called “Bentham’s calculus.”
- 7.
Bentham advocated taking into consideration not only all people affected, but also members of other animal species. Since pleasure and pain are the relevant consequences, and since animals are capable of suffering, he reckoned that they should be included in the utility calculus.
- 8.
- 9.
More on this in Chap. 15 of this volume – “Ethics, Justice, and the Province of American Medicine: A Discussion of the Politicalization of the Duty to Care for Pediatric Heart Transplant Patients who are in the Country Illegally.” The distinction between negative and positive rights also plays a role in the abortion debate (see Chap. 10 – “Abortion Rights”).
- 10.
The first formulation of the Categorical Imperative reads: “Act only according to that maxim whereby you can, at the same time, will that it should become a universal law.” The idea is that one should act only in a way that one could will that everyone act in like circumstances. The principle is close to the Golden Rule, but Kant’s emphasis is not on whether I would in fact want everyone else to act in this way, but whether it is logically possible for everyone to act in this way. His best example—if everyone were to lie when it is convenient, no one would believe anyone ever, and lying itself would become impossible. The practice of lying whenever convenient cannot, without self-contradiction, become a universal practice. According to Kant, lying is thus prohibited by the Categorical Imperative, and hence immoral.
- 11.
Deontologists would insist, though, that there are certain contracts which are necessarily null and void and cannot be entered into. For example, one cannot contract to give up permanently one’s basic natural rights. So, for example, I may not contract to sell myself into slavery, for in doing so I would permanently destroy my freedom—the very freedom that I am exercising in making such an agreement. Kant would argue that there is a self-contradiction in such an arrangement. For similar reasons, Kant holds that suicide is always a violation of the moral law.
- 12.
See Chap. 10 of this volume – on “Abortion Rights” – for a more detailed discussion of the abortion dilemma and different ways of depicting the conflict.
- 13.
The emphasis upon prima facie duties is derived from the work of Ross [16]. Ross denied that we can ever have a clear ranking of duties—from least stringent to most stringent—that would allow us reliably to resolve conflicts between prima facie duties.
- 14.
- 15.
Alasdair McIntyre, in a widely discussed book entitled After Virtue [18], summed up the way things stand in the following well-known passage: “The most striking feature of contemporary moral utterance is that so much of it is used to express disagreement; and the most striking feature of the debates in which these disagreements are expressed is their interminable character. I do not mean by this just that such debates go on and on and on—although they do—but also that they apparently can find no terminus. There seems to be no way of securing moral agreement in our culture” (p. 6). There are certain issues regarding which MacIntyre’s weary description is accurate. But though they are high-profile issues (in great part because of their insolubility), they are not typical.
- 16.
Sonny Bal [21] tell us that, “In the United States, medical malpractice suits first appeared with regularity beginning in the 1800s. However, before the 1960s, legal claims for medical malpractice were rare, and had little impact on the practice of medicine. Since the 1960s the frequency of medical malpractice claims has increased…”
- 17.
Arguments from applied ethicists played an especially important role in the early debates on abortion legalization occurring in the late 1960s and early 1970s. See Chap. 10 of this volume – “Abortion Rights.”
- 18.
Mill’s On Liberty [22] can be interpreted as an extended utility-based argument in favor of respect for individual autonomy.
- 19.
The locus classicus for a broad discussion of the principles is Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics [23]. The work was first published in 1977 and is now in its seventh edition (2009).
- 20.
Currently the standard of due care does not require a doctor to let a patient die (though in certain circumstances it permits her to do so). Nor (at present) is the doctor required to provide the patient with the means to end his own life. But the latter development is not unimaginable, as a growing number of states have passed laws permitting physician-assisted death/suicide.
- 21.
Beauchamp and Childress, in turn, cite [24] as a source.
- 22.
Actually, this may not be true. Remarkable recent research suggests that in certain cases the placebo effect remains even when the patient is explicitly informed that the pill she is taking is a placebo (and the pill bottle is labeled as such) [25].
- 23.
“Informed Consent in Fetal Hypoplastic Left Heart Syndrome” (Chap. 13 of this volume) provides a nuanced discussion of this difficulty in the context of a diagnosis of hypoplastic left heart syndrome.
- 24.
There is interesting ethnographic data indicating that certain nationalities and certain ethnic sub-groups in the US and Canada are less in favor of a terminally ill competent adult family member’s being informed of the diagnosis and asked to participate in the decision-making [26, 27]. The film “The Farewell” (2019) explores this theme beautifully in the context of a Chinese-American family.
- 25.
Recent discussion of this issue was prompted in part by the publication of a book entitled Nudge, by Thaler and Sunstein [28]. Two chapters of our volume address related questions–—“Informed Consent” (Chap. 3) on a specific case and “Between Death and Donation: Ethical Considerations in Pediatric Heart Transplantation” (Chap. 18) on the related question of nudging family members to donate the organs of deceased relatives.
- 26.
In structuring the discussion in this way I am following the lead of David Miller in his excellent article in the Stanford Encyclopedia of Philosophy [29].
- 27.
For example, Marx’s famous principle: “From each according to his ability; to each according to his need” [31].
- 28.
Chapter 14 of this volume (“Role of Ethics Consultation in Pediatric Congenital Heart Disease”) provides insightful discussion and case studies of the role and value of the ethics consultation in the context of pediatric cardiac medicine and surgery.
- 29.
The concrete logistics of health care delivery make it inevitable that there will be conflicts that cannot be resolved as easily as this paragraph suggests. For example, many hospitals in the US are owned and supported by churches. The churches in question may impose restrictions on the medical procedures that may be performed – restrictions based on the church’s religious tenets and not shared by the wider community. For example, Catholic-affiliated hospitals restrict access to reproductive and end-of-life health services, counseling, and referrals. Cf. Ethical and Religious Directives for Catholic Healthcare Services, sixth Edition [32].
- 30.
A possible exception would be the intentional and open breaking of what one perceives to be an unjust law in order to call attention to it—as in the Civil Rights Movement. Martin Luther King, Jr. always explained that although the protesters broke specific unjust laws, they showed their respect for the law by willingly submitting to the legally mandated punishment.
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Cook, J.T. (2020). Introduction to Biomedical Ethics. In: Mavroudis, C., Cook, J., Mavroudis, C. (eds) Bioethical Controversies in Pediatric Cardiology and Cardiac Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-35660-6_1
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