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AMA Code of Medical Ethics
Medical ethics is an applied branch of ethics
which analyzes the practice of clinical medicine and related scientific
research. Medical ethics is based on a set of values that professionals
can refer to in the case of any confusion or conflict. These values
include the respect for autonomy, non-maleficence, beneficence, and justice. Such tenets may allow doctors, care providers, and families to create a treatment plan and work towards the same common goal.
It is important to note that these four values are not ranked in order
of importance or relevance and that they all encompass values pertaining
to medical ethics.
However, a conflict may arise leading to the need for hierarchy in an
ethical system, such that some moral elements overrule others with the
purpose of applying the best moral judgement to a difficult medical
situation. Medical ethics is particularly relevant in decisions regarding involuntary treatment and involuntary commitment.
There are several codes of conduct. The Hippocratic Oath discusses basic principles for medical professionals. This document dates back to the fifth century BCE. Both The Declaration of Helsinki (1964) and The Nuremberg Code
(1947) are two well-known and well respected documents contributing to
medical ethics. Other important markings in the history of medical
ethics include Roe v. Wade in 1973 and the development of hemodialysis
in the 1960s. More recently, new techniques for gene editing aiming at
treating, preventing and curing diseases utilizing gene editing, are
raising important moral questions about their applications in medicine
and treatments as well as societal impacts on future generations.
As this field continues to develop and change throughout history,
the focus remains on fair, balanced, and moral thinking across all
cultural and religious backgrounds around the world. The field of medical ethics encompasses both practical application in clinical settings and scholarly work in philosophy, history, and sociology.
Medical ethics encompasses beneficence, autonomy, and justice as
they relate to conflicts such as euthanasia, patient confidentiality,
informed consent, and conflicts of interest in healthcare.
In addition, medical ethics and culture are interconnected as different
cultures implement ethical values differently, sometimes placing more
emphasis on family values and downplaying the importance of autonomy.
This leads to an increasing need for culturally sensitive physicians and ethical committees in hospitals and other healthcare settings.
History
The term medical ethics first dates back to 1803, when English author and physician Thomas Percival
published a document describing the requirements and expectations of
medical professionals within medical facilities. The Code of Ethics was
then adapted in 1847, relying heavily on Percival's words. Over the years in 1903, 1912, and 1947, revisions have been made to the original document. The practice of Medical Ethics is widely accepted and practiced throughout the world.
Historically, Western medical ethics may be traced to guidelines on the duty of physicians in antiquity, such as the Hippocratic Oath, and early Christian teachings. The first code of medical ethics, Formula Comitis Archiatrorum, was published in the 5th century, during the reign of the Ostrogothic king Theodoric the Great. In the medieval and early modern period, the field is indebted to Islamic scholarship such as Ishaq ibn Ali al-Ruhawi (who wrote the Conduct of a Physician, the first book dedicated to medical ethics), Avicenna's Canon of Medicine and Muhammad ibn Zakariya ar-Razi (known as Rhazes in the West), Jewish thinkers such as Maimonides, Roman Catholic scholastic thinkers such as Thomas Aquinas, and the case-oriented analysis (casuistry) of Catholic moral theology. These intellectual traditions continue in Catholic, Islamic and Jewish medical ethics.
By the 18th and 19th centuries, medical ethics emerged as a more self-conscious discourse. In England, Thomas Percival,
a physician and author, crafted the first modern code of medical
ethics. He drew up a pamphlet with the code in 1794 and wrote an
expanded version in 1803, in which he coined the expressions "medical
ethics" and "medical jurisprudence".
However, there are some who see Percival's guidelines that relate to
physician consultations as being excessively protective of the home
physician's reputation. Jeffrey Berlant is one such critic who considers
Percival's codes of physician consultations as being an early example
of the anti-competitive, "guild"-like nature of the physician community.
In addition, since the mid 19th century up to the 20th century,
physician-patient relationships that once were more familiar became less
prominent and less intimate, sometimes leading to malpractice, which
resulted in less public trust and a shift in decision making power from
the paternalistic physician model to today's emphasis on patient autonomy and self-determination.
In 1815, the Apothecaries Act was passed by the Parliament of the United Kingdom.
It introduced compulsory apprenticeship and formal qualifications for
the apothecaries of the day under the license of the Society of
Apothecaries. This was the beginning of regulation of the medical
profession in the UK.
In 1847, the American Medical Association adopted its first code of ethics, with this being based in large part upon Percival's work. While the secularized field borrowed largely from Catholic medical ethics, in the 20th century a distinctively liberal Protestant approach was articulated by thinkers such as Joseph Fletcher. In the 1960s and 1970s, building upon liberal theory and procedural justice, much of the discourse of medical ethics went through a dramatic shift and largely reconfigured itself into bioethics.
Well-known medical ethics cases include:
Since the 1970s, the growing influence of ethics in contemporary medicine can be seen in the increasing use of Institutional Review Boards
to evaluate experiments on human subjects, the establishment of
hospital ethics committees, the expansion of the role of clinician
ethicists, and the integration of ethics into many medical school
curricula.
Values
A common framework used in the analysis of medical ethics is the "four principles" approach postulated by Tom Beauchamp and James Childress in their textbook Principles of biomedical ethics.
It recognizes four basic moral principles, which are to be judged and
weighed against each other, with attention given to the scope of their
application. The four principles are:
- Respect for autonomy – the patient has the right to refuse or choose their treatment.
- Beneficence – a practitioner should act in the best interest of the patient.
- Non-maleficence – to not be the cause of harm. Also, "Utility" – to promote more good than harm.
- Justice – concerns the distribution of scarce health resources, and the decision of who gets what treatment.
Autonomy
The principle of autonomy, broken down into "autos" (self) and "nomos (rule), views the rights of an individual to self-determination. This is rooted in society's respect for individuals' ability to make informed decisions about personal matters with freedom.
Autonomy has become more important as social values have shifted to
define medical quality in terms of outcomes that are important to the
patient and their family rather than medical professionals. The increasing importance of autonomy can be seen as a social reaction against the "paternalistic" tradition within healthcare.
Some have questioned whether the backlash against historically
excessive paternalism in favor of patient autonomy has inhibited the
proper use of soft paternalism to the detriment of outcomes for some patients.
The definition of autonomy is the ability of an individual to
make a rational, uninfluenced decision. Therefore, it can be said that
autonomy is a general indicator of a healthy mind and body. The
progression of many terminal diseases are characterized by loss of
autonomy, in various manners and extents. For example, dementia,
a chronic and progressive disease that attacks the brain can induce
memory loss and cause a decrease in rational thinking, almost always
results in the loss of autonomy.
Psychiatrists and clinical psychologists are often asked to
evaluate a patient's capacity for making life-and-death decisions at the
end of life. Persons with a psychiatric condition such as delirium or
clinical depression may lack capacity to make end-of-life decisions. For
these persons, a request to refuse treatment may be taken in the
context of their condition. Unless there is a clear advance directive to
the contrary, persons lacking mental capacity are treated according to
their best interests. This will involve an assessment involving people
who know the person best to what decisions the person would have made
had they not lost capacity.
Persons with the mental capacity to make end-of-life decisions may
refuse treatment with the understanding that it may shorten their life.
Psychiatrists and psychologists may be involved to support decision
making.
Beneficence
The term beneficence refers to actions that promote the well being of
others. In the medical context, this means taking actions that serve
the best interests of patients and their families. However, uncertainty surrounds the precise definition of which practices do in fact help patients.
James Childress and Tom Beauchamp in Principle of Biomedical Ethics (1978) identify beneficence as one of the core values of healthcare ethics. Some scholars, such as Edmund Pellegrino, argue that beneficence is the only
fundamental principle of medical ethics. They argue that healing should
be the sole purpose of medicine, and that endeavors like cosmetic surgery and euthanasia are severely unethical and against the Hippocratic Oath.
Non-maleficence
The concept of non-maleficence is embodied by the phrase, "first, do no harm," or the Latin, primum non nocere. Many consider that should be the main or primary consideration (hence primum):
that it is more important not to harm your patient, than to do them
good, which is part of the Hippocratic oath that doctors take.
This is partly because enthusiastic practitioners are prone to using
treatments that they believe will do good, without first having
evaluated them adequately to ensure they do no harm to the patient. Much
harm has been done to patients as a result, as in the saying, "The
treatment was a success, but the patient died." It is not only more
important to do no harm than to do good; it is also important to know
how likely it is that your treatment will harm a patient. So a
physician should go further than not prescribing medications they know
to be harmful—he or she should not prescribe medications (or otherwise
treat the patient) unless s/he knows that the treatment is unlikely to
be harmful; or at the very least, that patient understands the risks and
benefits, and that the likely benefits outweigh the likely risks.
In practice, however, many treatments carry some risk of harm. In
some circumstances, e.g. in desperate situations where the outcome
without treatment will be grave, risky treatments that stand a high
chance of harming the patient will be justified, as the risk of not
treating is also very likely to do harm. So the principle of non-maleficence is not absolute, and balances against the principle of beneficence (doing good), as the effects of the two principles together often give rise to a double effect
(further described in next section). Even basic actions like taking a
blood sample or an injection of a drug cause harm to the patient's body.
Euthanasia also goes against the principle of beneficence because the patient dies as a result of the medical treatment by the doctor.
Double effect
Double effect refers to two types of consequences that may be produced by a single action, and in medical ethics it is usually regarded as the combined effect of beneficence and non-maleficence.
A commonly cited example of this phenomenon is the use of morphine or other analgesic
in the dying patient. Such use of morphine can have the beneficial
effect of easing the pain and suffering of the patient while
simultaneously having the maleficent effect of shortening the life of
the patient through the deactivation of the respiratory system.
Respect for human rights
The human rights era started with the formation of the United Nations in 1945, which was charged with the promotion of human rights. The Universal Declaration of Human Rights
(1948) was the first major document to define human rights. Medical
doctors have an ethical duty to protect the human rights and human dignity of the patient so the advent of a document that defines human rights has had its effect on medical ethics. Most codes of medical ethics now require respect for the human rights of the patient.
The Council of Europe promotes the rule of law and observance of human rights in Europe. The Council of Europe adopted the European Convention on Human Rights and Biomedicine (1997) to create a uniform code of medical ethics for its 47 member-states. The Convention applies international human rights law
to medical ethics. It provides special protection of physical integrity
for those who are unable to consent, which includes children.
No organ or tissue removal may be carried out on a person who does not have the capacity to consent under Article 5.
As of December 2013, the Convention had been ratified or acceded to by twenty-nine member-states of the Council of Europe.
The United Nations Educational, Scientific and Cultural Organization (UNESCO) also promotes the protection of human rights and human dignity.
According to UNESCO, "Declarations are another means of defining norms,
which are not subject to ratification. Like recommendations, they set
forth universal principles to which the community of States wished to
attribute the greatest possible authority and to afford the broadest
possible support." UNESCO adopted the Universal Declaration on Human Rights and Biomedicine
to advance the application of international human rights law in medical
ethics. The Declaration provides special protection of human rights for
incompetent persons.
In applying and advancing scientific knowledge, medical practice and
associated technologies, human vulnerability should be taken into
account. Individuals and groups of special vulnerability should be
protected and the personal integrity of such individuals respected.
Solidarity
Individualistic
standards of autonomy and personal human rights as they relate to
social justice seen in the Anglo-Saxon community, clash with and can
also supplement the concept of solidarity, which stands closer to a
European healthcare perspective focused on community, universal welfare,
and the unselfish wish to provide healthcare equally for all.
In the United States individualistic and self-interested healthcare
norms are upheld, whereas in other countries, including European
countries, a sense of respect for the community and personal support is
more greatly upheld in relation to free healthcare.
Acceptance of Ambiguity in Medicine
The
concept of normality, that there is a human physiological standard
contrasting with conditions of illness, abnormality and pain, leads to
assumptions and bias that negatively affects health care practice.
It is important to realize that normality is ambiguous and that
ambiguity in healthcare and the acceptance of such ambiguity is
necessary in order to practice humbler medicine and understand complex,
sometimes unusual usual medical cases.
Thus, society's views on central concepts in philosophy and clinical
beneficence must be questioned and revisited, adopting ambiguity as a
central player in medical practice.
Conflicts
Between autonomy and beneficence/non-maleficence
Autonomy
can come into conflict with beneficence when patients disagree with
recommendations that healthcare professionals believe are in the
patient's best interest. When the patient's interests conflict with the
patient's welfare, different societies settle the conflict in a wide
range of manners. In general, Western medicine defers to the wishes of a
mentally competent patient to make their own decisions, even in cases
where the medical team believes that they are not acting in their own
best interests. However, many other societies prioritize beneficence
over autonomy.
Examples include when a patient does not want a treatment because of, for example, religious or cultural views. In the case of euthanasia, the patient, or relatives of a patient, may want to end the life of the patient. Also, the patient may want an unnecessary treatment, as can be the case in hypochondria or with cosmetic surgery;
here, the practitioner may be required to balance the desires of the
patient for medically unnecessary potential risks against the patient's
informed autonomy in the issue. A doctor may want to prefer autonomy
because refusal to please the patient's self-determination would harm
the doctor-patient relationship.
Organ donations can sometimes pose interesting scenarios, in which a patient is classified as a non-heart beating donor (NHBD),
where life support fails to restore the heartbeat and is now considered
futile but brain death has not occurred. Classifying a patient as a
NHBD can qualify someone to be subject to non-therapeutic intensive
care, in which treatment is only given to preserve the organs that will
be donated and not to preserve the life of the donor. This can bring up
ethical issues as some may see respect for the donors wishes to donate
their healthy organs as respect for autonomy, while others may view the
sustaining of futile treatment during vegetative state maleficence for
the patient and the patient's family. Some are worried making this
process a worldwide customary measure may dehumanize and take away from
the natural process of dying and what it brings along with it.
Individuals' capacity for informed decision-making may come into
question during resolution of conflicts between autonomy and
beneficence. The role of surrogate medical decision-makers is an
extension of the principle of autonomy.
On the other hand, autonomy and beneficence/non-maleficence may
also overlap. For example, a breach of patients' autonomy may cause
decreased confidence for medical services in the population and
subsequently less willingness to seek help, which in turn may cause
inability to perform beneficence.
The principles of autonomy and beneficence/non-maleficence may
also be expanded to include effects on the relatives of patients or even
the medical practitioners, the overall population and economic issues
when making medical decisions.
Euthanasia
There is disagreement among American physicians as to whether the
non-maleficence principle excludes the practice of euthanasia. Euthanasia is currently legal in the states of Washington DC, California, Colorado, Oregon, Vermont, and Washington. Around the world, there are different organizations that campaign to change legislation about the issue of physician-assisted death, or PAD. Examples of such organizations are the Hemlock Society of the United States and the Dignity in Dying campaign in the United Kingdom.
These groups believe that doctors should be given the right to end a
patient's life only if the patient is conscious enough to decide for
themselves, is knowledgeable about the possibility of alternative care,
and has willingly asked to end their life or requested access to the
means to do so.
This argument is disputed in other parts of the world. For
example, in the state of Louisiana, giving advice or supplying the means
to end a person's life is considered a criminal act and can be charged
as a felony. In state courts, this crime is comparable to manslaughter. The same laws apply in the states of Mississippi and Nebraska.
Informed consent
Informed consent in ethics usually refers to the idea that a person
must be fully informed about and understand the potential benefits and
risks of their choice of treatment. A correlate to "informed consent" is the concept of informed refusal.
An uninformed person is at risk of mistakenly making a choice not
reflective of his or her values or wishes. It does not specifically mean
the process of obtaining consent, or the specific legal requirements,
which vary from place to place, for capacity to consent. Patients can
elect to make their own medical decisions or can delegate
decision-making authority to another party.
If the patient is incapacitated, laws around the world designate
different processes for obtaining informed consent, typically by having a
person appointed by the patient or their next of kin make decisions for them. The value of informed consent is closely related to the values of autonomy and truth telling.
Confidentiality
Confidentiality is commonly applied to conversations between doctors and patients.
This concept is commonly known as patient-physician privilege. Legal
protections prevent physicians from revealing their discussions with
patients, even under oath in court.
Confidentiality is mandated in the United States by the Health Insurance Portability and Accountability Act of 1996 known as HIPAA,
specifically the Privacy Rule, and various state laws, some more
rigorous than HIPAA. However, numerous exceptions to the rules have been
carved out over the years. For example, many states require physicians
to report gunshot wounds to the police and impaired drivers to the Department of Motor Vehicles.
Confidentiality is also challenged in cases involving the diagnosis of a
sexually transmitted disease in a patient who refuses to reveal the
diagnosis to a spouse, and in the termination of a pregnancy in an
underage patient, without the knowledge of the patient's parents. Many
states in the U.S. have laws governing parental notification in underage
abortion. Those working in mental health have a duty to warn those who they deem to be at risk from their patients in some countries.
Traditionally, medical ethics has viewed the duty of
confidentiality as a relatively non-negotiable tenet of medical
practice. More recently, critics like Jacob Appel have argued for a more nuanced approach to the duty that acknowledges the need for flexibility in many cases.
Confidentiality is an important issue in primary care ethics,
where physicians care for many patients from the same family and
community, and where third parties often request information from the
considerable medical database typically gathered in primary health care.
Privacy and the Internet
In
increasing frequency, medical researchers are researching activities in
online environments such as discussion boards and bulletin boards, and
there is concern that the requirements of informed consent and privacy
are not applied, although some guidelines do exist.
One issue that has arisen, however, is the disclosure of
information. While researchers wish to quote from the original source in
order to argue a point, this can have repercussions when the identity
of the patient is not kept confidential. The quotations and other
information about the site can be used to identify the patient, and
researchers have reported cases where members of the site, bloggers and
others have used this information as 'clues' in a game in an attempt to
identify the site. Some researchers have employed various methods of "heavy disguise." including discussing a different condition from that under study.
Healthcare institutions' websites have the responsibility to
ensure that the private medical records of their online visitors are
secure from being marketed and monetized into the hands of drug
companies, occupation records, and insurance companies. The delivery of
diagnosis online leads patients to believe that doctors in some parts of
the country are at the direct service of drug companies, finding
diagnosis as convenient as what drug still has patent rights on it.
Physicians and drug companies are found to be competing for top ten
search engine ranks to lower costs of selling these drugs with little to
no patient involvement.
With the expansion of internet healthcare platforms, online
practitioner legitimacy and privacy accountability face unique
challenges such as e-paparazzi, online information brokers, industrial
spies, unlicensed information providers that work outside of traditional
medical codes for profit. The American Medical Association (AMA)
states that medical websites have the responsibility to ensure the
health care privacy of online visitors and protect patient records from
being marketed and monetized into the hands of insurance companies,
employers, and marketers.
With the rapid unification of healthcare, business practices, computer
science and e-commerce to create these online diagnostic websites,
efforts to maintain health care system's ethical confidentiality
standard need to keep up as well. Over the next few years, the
Department of Health and Human Services has stated that they will be
working towards lawfully protecting the online privacy and digital
transfers of patient Electronic Medical Records (EMR) under The Health
Insurance Portability and Accountability Act (HIPAA).
Control and resolution
To ensure that appropriate ethical values are being applied within hospitals, effective hospital accreditation requires that ethical considerations are taken into account, for example with respect to physician integrity, conflict of interest, research ethics and organ transplantation ethics.
Guidelines
There
is much documentation of the history and necessity of the Declaration
of Helsinki. The first code of conduct for research including medical
ethics was the Nuremberg Code. This document had large ties to Nazi war
crimes, as it was introduced in 1997, so it didn't make much of a
difference in terms of regulating practice. This issue called for the
creation of the Declaration. There are some stark differences between
the Nuremberg Code and the Declaration of Helsinki, including the way it
is written. Nuremberg was written in a very concise manner, with a
simple explanation. The Declaration of Helsinki is written with a
thorough explanation in mind and including many specific commentaries.
In the United Kingdom, General Medical Council provides clear overall modern guidance in the form of its 'Good Medical Practice' statement. Other organizations, such as the Medical Protection Society and a number of university departments, are often consulted by British doctors regarding issues relating to ethics.
Ethics committees
Often, simple communication is not enough to resolve a conflict, and a hospital ethics committee must convene to decide a complex matter.
These bodies are composed primarily of healthcare professionals, but may also include philosophers, lay people, and clergy – indeed, in many parts of the world their presence is considered mandatory in order to provide balance.
With respect to the expected composition of such bodies in the US, Europe and Australia, the following applies.
U.S. recommendations suggest that Research and Ethical Boards (REBs)
should have five or more members, including at least one scientist, one
non-scientist, and one person not affiliated with the institution. The REB should include people knowledgeable in the law and standards of practice and professional conduct. Special memberships are advocated for handicapped or disabled concerns, if required by the protocol under review.
The European Forum for Good Clinical Practice (EFGCP) suggests
that REBs include two practicing physicians who share experience in
biomedical research and are independent from the institution where the
research is conducted; one lay person; one lawyer; and one paramedical
professional, e.g. nurse or pharmacist. They recommend that a quorum
include both sexes from a wide age range and reflect the cultural
make-up of the local community.
The 1996 Australian Health Ethics Committee recommendations were
entitled, "Membership Generally of Institutional Ethics Committees".
They suggest a chairperson be preferably someone not employed or
otherwise connected with the institution. Members should include a
person with knowledge and experience in professional care, counseling or
treatment of humans; a minister of religion or equivalent, e.g.
Aboriginal elder; a layman; a laywoman; a lawyer and, in the case of a
hospital-based ethics committee, a nurse.
The assignment of philosophers or religious clerics will reflect the importance attached by the society to the basic values involved. An example from Sweden with Torbjörn Tännsjö on a couple of such committees indicates secular trends gaining influence.
Cultural concerns
Cultural differences can create difficult medical ethics problems. Some cultures have spiritual or magical theories about the origins and cause of disease, for example, and reconciling these beliefs with the tenets of Western medicine
can be very difficult. As different cultures continue to intermingle
and more cultures live alongside each other, the healthcare system,
which tends to deal with important life events such as birth, death and
suffering, increasingly experiences difficult dilemmas that can
sometimes lead to cultural clashes and conflict. Efforts to respond in a
culturally sensitive manner go hand in hand with a need to distinguish
limits to cultural tolerance.
Culture and Language
As
more people from different cultural and religious backgrounds move to
other countries, among these, the United States, it is becoming
increasingly important to be culturally sensitive to all communities in
order to provide the best health care for all people.
Lack of cultural knowledge can lead to misunderstandings and even
inadequate care, which can lead to ethical problems. A common complaint
patients have is feeling like they are not being heard, or perhaps,
understood.
Preventing escalating conflict can be accomplished by seeking
interpreters, noticing body language and tone of both yourself and the
patient as well as attempting to understand the patient's perspective in
order to reach an acceptable option.
Some believe most medical practitioners in the future will have
to be or greatly benefit from being bilingual. In addition to knowing
the language, truly understanding culture is best for optimal care.
Recently, a practice called 'narrative medicine' has gained some
interest as it has a potential for improving patient-physician
communication and understanding of patient's perspective. Interpreting a
patient's stories or day-to-day activities as opposed to standardizing
and collecting patient data may help in acquiring a better sense of what
each patient needs, individually, with respect to their illness.
Without this background information, many physicians are unable to
properly understand the cultural differences that may set two different
patients apart, and thus, may diagnose or recommend treatments that are
culturally insensitive or inappropriate. In short, patient narrative has
the potential for uncovering patient information and preferences that
may otherwise be overlooked.
Medical humanitarianism
In
order to address the underserved, uneducated communities in need of
nutrition, housing, and healthcare disparities seen in much of the world
today, some argue that we must fall back on ethical values in order to
create a foundation to move towards a reasonable understanding, which
encourages commitment and motivation to improve factors causing
premature death as a goal in a global community.
Such factors -such as poverty, environment and education- are said to
be out of national or individual control and so this commitment is by
default a social and communal responsibility placed on global
communities that are able to aid others in need.
This is based on the framework of 'provincial globalism,' which seeks a
world in which all people have the capability to be healthy.
One concern regarding the intersection of medical ethics and
humanitarian medical aid is how medical assistance can be as harmful as
it is helpful to the community being served. One such example being how
political forces may control how foreign humanitarian aid can be
utilized in the region it is meant to be provided in. This would be
congruous in situations where political strife could lead such aid being
used in favor of one group over another. Another example of how foreign
humanitarian aid can be misused in its intended community includes the
possibility of dissonance forming between a foreign humanitarian aid
group and the community being served.
Examples of this could include the relationships being viewed between
aid workers, style of dress, or the lack of education regarding local
culture and customs.
Humanitarian practices in areas lacking optimum care can also
pause other interesting and difficult ethical dilemmas in terms of
beneficence and non-maleficence. Humanitarian practices are based upon
providing better medical equipment and care for communities whose
country does not provide adequate healthcare.
The issues with providing healthcare to communities in need may
sometimes be religious or cultural backgrounds keeping people from
performing certain procedures or taking certain drugs. On the other
hand, wanting certain procedures done in a specific manner due to
religious or cultural belief systems may also occur. The ethical dilemma
stems from differences in culture between communities helping those
with medical disparities and the societies receiving aid. Women's
rights, informed consent and education about health become
controversial, as some treatments needed are against societal law, while
some cultural traditions involve procedures against humanitarian
efforts. Examples of this are female genital mutilation (FGM), aiding in reinfibulation,
providing sterile equipment in order to perform procedures such as FGM,
as well as informing patients of their HIV positive testing. The latter
is controversial because certain communities have in the past outcast
or killed HIV positive individuals.
Healthcare reform and Lifestyle
Leading
causes of death in the United States and around the world are highly
related to behavioral consequences over genetic or environmental
factors. This leads some to believe true healthcare reform begins with cultural reform, habit and overall lifestyle.
Lifestyle, then, becomes the cause of many illnesses and the illnesses
themselves are the result or side-effect of a larger problem.
Some people believe this to be true and think that cultural change is
needed in order for developing societies to cope and dodge the negative
effects of drugs, food and conventional modes of transportation
available to them.
In 1990, tobacco use, diet, and exercise alone accounted for close to
80 percent of all premature deaths and continue to lead in this way
through the 21st century. Heart disease, stroke, dementia, and diabetes are some of the diseases that may be affected by habit-forming patterns throughout our life.
Some believe that medical lifestyle counseling and building healthy
habits around our daily lives is one way to tackle health care reform.
Other Cultures and Healthcare
Buddhist medicine
Buddhist ethics and medicine are based on religious teachings of compassion and understanding
of suffering and cause and effect and the idea that there is no
beginning or end to life, but that instead there are only rebirths in an
endless cycle.
In this way, death is merely a phase in an indefinitely lengthy process
of life, not an end. However, Buddhist teachings support living one's
life to the fullest so that through all the suffering which encompasses a
large part of what is life, there are no regrets. Buddhism accepts
suffering as an inescapable experience, but values happiness and thus
values life.
Because of this suicide, and euthanasia, are prohibited. However,
attempts to rid oneself of any physical or mental pain and suffering are
seen as good acts. On the other hand, sedatives and drugs are thought
to impair consciousness and awareness in the dying process, which is
believed to be of great importance, as it is thought that one's dying
consciousness remains and affects new life. Because of this, analgesics
must not be part of the dying process, in order for the dying person to
be present entirely and pass on their consciousness wholesomely. This
can pose significant conflicts during end of life care in Western
medical practice.
Taoist symbol of Yin and Yang
Chinese Medicine
In traditional Chinese philosophy,
human life is believed to be connected to nature, which is thought of
as the foundation and encompassing force sustaining all of life's
phases.
Passing and coming of the seasons, life, birth and death are perceived
as a cyclic and perpetual occurrences that are believed to be regulated
by the principles of yin and yang. When one dies, the life-giving material force referred to as ch'i,
encompassing both body and spirit, rejoins the material force of the
universe and cycles on with respect to the rhythms set forth by yin and yang.
Because many Chinese people believe that circulation of both
physical and 'psychic energy' is important to stay healthy, procedures
which require surgery, as well as donations and transplantations of
organs, are seen as a loss of ch'i , resulting in the loss of
someone's vital energy supporting their consciousness and purpose in
their lives. Furthermore, a person is never seen as a single unit but
rather as a source of relationship, interconnected in a social web.
Thus, it is believed that what makes a human one of us is relatedness
and communication and family is seen as the basic unit of a community.
This can greatly affect the way medical decisions are made among family
members, as diagnoses are not always expected to be announced to the
dying or sick, the elderly are expected to be cared for and represented
by their children and physicians are expected to act in a paternalistic
way. In short, informed consent as well as patient privacy can be difficult to enforce when dealing with Confucian families.
Furthermore, some Chinese people may be inclined to continue
futile treatment in order to extend life and allow for fulfillment of
the practice of benevolence and humanity. In contrast, patients with strong Daoist
beliefs may see death as an obstacle and dying as a reunion with nature
that should be accepted, and are therefore less likely to ask for
treatment of an irreversible condition.
Islamic culture and medicine
Some
believe Islamic medical ethics and framework remain poorly understood
by many working in healthcare. It is important to recognize that for
people of Islamic faith, Islam envelops and affects all aspects of life,
not just medicine.
Because many believe it is faith and a supreme deity that hold the cure
to illness, it is common that the physician is viewed merely as help or
intermediary player during the process of healing or medical care.
In addition to Chinese culture's emphasis on family as the basic
unit of a community intertwined and forming a greater social construct,
Islamic traditional medicine also places importance on the values of
family and the well-being of a community. Many Islamic communities uphold paternalism as an acceptable part of medical care.
However, autonomy and self-rule is also valued and protected and, in
Islamic medicine, it is particularly upheld in terms of providing and
expecting privacy in the healthcare setting. An example of this is
requesting same gender providers in order to retain modesty. Overall, Beauchamp's principles of beneficence, non-maleficence and justice are promoted and upheld in the medical sphere with as much importance as in Western culture. In contrast, autonomy is important but more nuanced. Furthermore, Islam also brings forth the principles of jurisprudence, Islamic law and legal maxims, which also allow for Islam to adapt to an ever-changing medical ethics framework.
Conflicts of interest
Physicians should not allow a conflict of interest
to influence medical judgment. In some cases, conflicts are hard to
avoid, and doctors have a responsibility to avoid entering such
situations. Research has shown that conflicts of interests are very
common among both academic physicians and physicians in practice.
Referral
Doctors who receive income from referring patients for medical tests have been shown to refer more patients for medical tests. This practice is proscribed by the American College of Physicians Ethics Manual. Fee splitting
and the payments of commissions to attract referrals of patients is
considered unethical and unacceptable in most parts of the world.
Vendor relationships
Studies show that doctors can be influenced by drug company inducements, including gifts and food. Industry-sponsored Continuing Medical Education (CME) programs influence prescribing patterns. Many patients surveyed in one study agreed that physician gifts from drug companies influence prescribing practices.
A growing movement among physicians is attempting to diminish the
influence of pharmaceutical industry marketing upon medical practice, as
evidenced by Stanford University's ban on drug company-sponsored
lunches and gifts. Other academic institutions that have banned
pharmaceutical industry-sponsored gifts and food include the Johns
Hopkins Medical Institutions, University of Michigan, University of
Pennsylvania, and Yale University.
Treatment of family members
The American Medical Association (AMA) states that "Physicians generally should not treat themselves or members of their immediate family".
This code seeks to protect patients and physicians because professional
objectivity can be compromised when the physician is treating a loved
one. Studies from multiple health organizations have illustrated that
physician-family member relationships may cause an increase in
diagnostic testing and costs.
Many doctors still treat their family members. Doctors who do so must
be vigilant not to create conflicts of interest or treat
inappropriately.
Physicians that treat family members need to be conscious of
conflicting expectations and dilemmas when treating relatives, as
established medical ethical principles may not be morally imperative
when family members are confronted with serious illness.
Sexual relationships
Sexual relationships between doctors and patients can create ethical conflicts, since sexual consent may conflict with the fiduciary responsibility of the physician.
Out of the many disciplines in current medicine, there are studies that
have been conducted in order to ascertain the occurrence of
Doctor-Patient sexual misconduct. Results from those studies appear to
indicate that certain disciplines are more likely to be offenders than
others. Psychiatrists and Obstetrician-Gynecologists for example, are
two disciplines noted for having a higher rate of sexual misconduct.
The violation of ethical conduct between doctors and patients also has
an association with the age and sex of doctor and patient. Male
physicians aged 40–49 and 50–59 years are two groups that have been
found to be more likely to have been reported for sexual misconduct,
while women aged 20–39 have been found to make up a significant portion
of reported victims of sexual misconduct. Doctors who enter into sexual relationships with patients face the threats of losing their medical license and prosecution. In the early 1990s, it was estimated that 2–9% of doctors had violated this rule.
Sexual relationships between physicians and patients' relatives may
also be prohibited in some jurisdictions, although this prohibition is
highly controversial.
Futility
In some hospitals, medical futility is referred to as treatment unable to benefit the patient. An important part of practicing good medical ethics is by attempting to avoid futility by practicing non-maleficence.
What should be done if there is no chance that a patient will survive
or benefit from a potential treatment but the family members insist on
advanced care?
Previously, some articles defined futility as the patient having less
than a one percent chance of surviving. Some of these cases are examined
in court.
Advance directives include living wills and durable powers of attorney for health care. In many cases, the "expressed wishes" of the patient are documented in
these directives, and this provides a framework to guide family members
and health care
professionals in the decision-making process when the patient is
incapacitated. Undocumented expressed wishes can also help guide
decisions in the absence of advance directives, as in the Quinlan case in Missouri.
"Substituted judgment" is the concept that a family member can
give consent for treatment if the patient is unable (or unwilling) to
give consent themselves. The key question for the decision-making
surrogate is not, "What would you like to do?", but instead, "What do
you think the patient would want in this situation?".
Courts have supported family's arbitrary definitions of futility to include simple biological survival, as in the Baby K
case (in which the courts ordered a child born with only a brain stem
instead of a complete brain to be kept on a ventilator based on the
religious belief that all life must be preserved).
Baby Doe Law
establishes state protection for a disabled child's right to life,
ensuring that this right is protected even over the wishes of parents or
guardians in cases where they want to withhold treatment.
