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Chapter 1 An Introduction to Modern, Evidence-Based Medical Ethics

The Definition and Evolution of Medical Ethics


Ethics is a branch of philosophy centered on the study of the moral principles that define a standard of human conduct for an individual, group, or culture. The action of an individual or group, the motivation behind that action, and the end result of that action is ofthen judged as being good or moral when scrutinized by the eyes of ethical philosophy. The choices of an individual, based on their personal moral beliefes, can have a consequential effect on other people or society at large. As a result, ethical standards are often applied to the general public in the form of policies and laws. Ethics can also be applied to various professions in order to define a level of responsibility or a standard code of performance for those in the field. The study of how the practice of medicine correlates with acceptable conduct is specifically termed medical ethics. National medical organizations have created ethical manuals to suggest guidelines for the ethical practice of medicine. Additionally, state medical boards that offer licensing for health care professionals also have regulations for obtaining and maintaining licensure based on standards of ethical practice. However, despite written directives for addressing common challenges, the practice of clinical medicine inherently will be fraught with unforseen ethical dilemmas, since both the health care practitioner and the patiend will bring their individual life experience and moral values to the clinical encounter. It is the job of the practitioner to find a balance between fundamental ethical principles, the law, and respect for the values of the patient.

On Medical Oaths, Codes of Ethics, and the Lessons of History


The Oath of Hippocrates likely written in the Fifth Century B.C., and set forth a code of conduct for physicians to follow. Although still revered within its historical context, the Oath is vague regarding most of its implications for ethical clinical practice. Exceptions to this ambiguity include its specific support of respect for patient confidentiality and its strict prohibition of abortion, euthanasia, and sexual relationships between physician and patient. The Oath has been modified numerous times over the years and, since early 1800s, it has been used in various forms at many medical school commencement ceremonies.

Some have contended that the Oath holds little relevance in modern medicine and that it is politically incorrect as it, for one example, refers to the medical care of slaves. It has been additionally argued that a one-time reading aloud of a doctrine, without contingent penalties for non-adherence to its principles, does not ensure the future ethical practice of any given practititoner. As a result, some institutions, such as the University of Massachusetts Medical School, have taken a different approach to the concept of the medical oath, the school holds an annual Oath Ceremony at the completion of the first two basic science years of training, just prior to entering the subsequent two years of clinical rotations. At the event students read an alternative oath of theirn own creation that reflects the scientific, ethical, and humanistic sides of medicine. Students are encouraged to develop an oath that states, in their own words, what it means to be a physician and what sort of person you (sic) would like to be as physician. The oath is reinforced at commencement excercises two years later, when students additionally recite the Oath of Maimonides an edict which encourages physicians in its central theme to never see in the patient anything but a fellow creature in pain. The need for greater detail and clarity as tpo what ethical guidelines a physician must follow in practyice beyond a once-recited oath has generated formalized codes of physican conduct. Some 24 centuries after the original Oath of Hippocrates, athe first meeting of the Americal Medical Association (AMA) in 1847, the organizations first Code of Ethics was approved. This Code sought not only to establish rules of professional behavior, but also to clarify the training requirements necessary to become a practicing physician. The Code of Ethics has since gone through several necessary revisions, largely reflecting changes in medical technology and in the social climate of this country. Exactly one century later, in the Doctors Trial of 1947 Germany, the indictment and prosecution of several Nazi physicians accused of human experimentation practices that included torture and murder, resulted in the tribunals development of the Nuremberg Code. Largely relying on the principles of the Oath of Hippocrates and established standards of medical ethgics at the time, the Nuremberg code was a landmark document for p[romoting human rights protection in research. The concept of informed voluntary consent came forth from this document, as well as the right of thereasearch subject to electivilu cease their involvement in a study at any time. All in all, the 10 decrfess in the Nuremberg Code formed thae basis for all modern day research regulations that protect the participants. Since Nuremberg, and paralleling the equal rights movement and the increasing diversity of the population in our country, medicine has undergone a significant shift from a strictly paternalistic approach to one that embraces the rights of the individual as well as the concept of cultural competence. One certainly can argue, however, that this metamorphosis has been difficult at times, slow in evolution, and is by no means complete. Historical events, such as the Tuskege

Syphilis Study, have marred the reputation of health care in, possibly, an irremediably way.

The Principle of Respect for Autonomy


Capable patients must be allowed to accept or refuse recommended medical interventions. Autonomy is defined as the capacity for self-determinations or the capacity to make ones own decisions. In the health care context, this capacity involves the ability to make and communicate health care decisions. Respect for patient autonomy requires that those with this capacity be permitted to accept or refuse treatment alternatives recommended by their physicians. Of vital importance to the application of this principle is therequirement of voluntary informed consent. Capable patients must be provided with full, relevant, and truthful information about recommended treatments and any reasonable alternatives, including expected benefits, potential risks, and the results of refusing treatment altogether. They must understand this information and make a voluntary decision without coercion or undue influence. Controversies arise here over the determination of who is capable of making these decisions. For many patients this will be obvious, based on their age or medical condition. One controversy involves mature minors, young people below the legal age of consent (18 years). Some have argues that the cognitive development of those who are 15 to 17 years of age qualifies them to make their own medical decisions, another area of controversy involves those in the early and middle stages of Alzheimers disease. One solution is to evaluate the individual patients capacity to make medical decisions, recognizing that these patients may be able to make some decisions and not nbe able to make others, depending upon the amount and difficulty of the information involved and the consequences of that decision. Those whose decisionmaking capacity is questionable should still be provided with information they can understand and be allowed to make age- and capacity-appropriate decisions.

The Principle of Respect for Dignity


Patients, their families and surrogate decision makes, as well as health care providers, all have the right to dignity. The Principle of Respect for Dignity is meant to apply to everyone involved on the medical encounter. It is based onthe fundamental idea that all persons should

be treated with respect and dignity. Respect for persons and respect for their dignity applies whethere or not health care decisions are being made, and even to those who are not capable of making their own decisions. Respect for peoples dignity includes respect for their emotions, relationships, reasonable goals, privacy, and bodily integrity. Respecting these personal characteristics requires that they be acknowledged and taken into consideration in all medical encounters and in all aspects of patient care.

Chapter 3 Advance Directives: The Living Will and the Power of Attorney for Health Care
When patients are conscious and capable, the must be permitted to make their own health care decisions, based on the Principle of Respect for Autonomy. However, the most difficult decisions are often made when a patient is no longer conscious or capable of particiapating in the decision-making process. This will be the case with most decisions about how patients lives will end. In 1976 California passed the Natural Death Act and became the first state to offer its citizens a way to make their wishes for end-of-life care known in advance. Adult patients suffering from terminal illness or mortal injury can execute a written document that authorizes withholding or withdrawing life-sustaining procedures. If physicians honor this directive, they cannot be charged with criminal liability or unprofessional conduct. Other states followed with their own statutes authorizing what came to be known as the Living Will. The United States Supreme Court cases Cruzan v. Director, Missouri Department of Health concerned the efforts of Nancy Cruzans parents to have her feeding tubes removed after she had been maintained in a persistent vegetative state for seven years. The majority of the court decided that the parents would

need clear and convincing evidence of Nancys wishes before the feeding tubes could be removed. A Living Will, for example, would provied written evidence of a patients wishes about end-of-life medical treatment. Justice OConnor, writing in a concurring opinion, suggested that states consider authorizing the patients appointment of a proxyu to make health care decisions on her behalf. Following the Cruzan decision, many states added persistent vegetative state and withholding and withdrawing artificial nutrition and hydration to their Living Will statutes. Many states also allowed citizens to appoint someone to make medical decisions for them when they could no longer do so, often termed a health care agent. Together the Living Will and the document uses to appoint a health care agent have come to be known as advance directives. Advance Directive is the term used to refer to any document that makes the wishes of a capable patient clear for a time in the future when the patient is no longer able to make or communicate health care decisions. When the patient is not capable of making health care decisions, as is often the case at the end of life, the Principles of Respect for Autonomy and Respect for not want their lives sustained in the event of certain medical conditions. In states where a Power of Attoryney for Health Care is available, patients should be encouraged to appoint a health care agent to make medical decisions when they are no longer able to do so, and to discuss their wishes for end-of-life treatment with that person. This may reduce the conflicts that often arise between family members when no health care agent has been named.

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