UNIT THREE: MEDICAL ETHICS

Developments in science and technology in the twentieth century have led to advances in medicine and health care
that have benefited millions of lives. The changing context in which health care is provided has created new
challenges for health workers, health researchers, and the broader health care of the community. Medical
professionals increasingly find themselves confronted with moral questions and ethical dilemmas. The need to
reflect on the moral dimension of advances in medical and health care, science, and technology, combined with the
desire to enhance public health efforts, has led to the establishment of a number of international ethical codes and
guidelines.

The medical profession is directly or indirectly tied up with the interests and welfare of the entire people. Admission
to the profession is by state license but the medical societies share in maintaining standards and in keeping unworthy
persons from entering the ranks. Medical ethics is a system of moral principles that apply values and judgments to
the practice of medicine. As a scholarly discipline, medical ethics encompasses its practical application in clinical
settings as well as work on its history, philosophy, theology, and sociology. This unit and the other preceding ones
attempt to show how ethics is applied in specific aspects of society and human life and how ethical problems and
issues affect human beings at all levels and in all areas of life. As a matter of fact, ethical problems arising in areas
such as medicine and business have caused a rival of interest in ethics, not only as theory or as an aspect of religion
but also as something that must be applied to human affairs in a practical way.

3.1. Definition of Terms

Medical ethics in the narrow historical sense refers to a group of guidelines, such as the Oath of Hippocrates,
generally written by physicians, about the physician’s ideal relationship to his peers and to his patients. Medical
ethics in the modern sense refers to the application of general and fundamental ethical principles to clinical practice
situations, including medical research. Individuals from various disciplines may author these principles. In recent
years, the term has been modified to biomedical ethics which includes ethical principles relating to all branches of
knowledge about life and health. Thus, fields not directly related to the practice of medicine are included, such as
nursing, pharmacy, genetics, social work, psychology, physiotherapy, occupational therapy, speech therapy, and the
like. In addition, bioethics addresses issues of medical administration, medical economics, industrial medicine,
epidemiology, legal medicine, treatment of animals, as well as environmental issues.

Bioethics means “life ethics,” or ethics in medicine. It covers a large area of concern than the phrase “medical
ethics,” which is often used to refer strictly to the doctor-patient relationship or to such issues as whether doctors
should advertise, split fees, or report incompetence within their ranks. Bioethics covers the following areas in
medicine: treatment of dying patients, allowing someone to die, mercy death and mercy killing; behavior control;
human experimentation and informed consent; genetics, fertilization and birth; health care delivery and its cost;
population and birth control, abortion and sterilization; allotment of scarce medical resources, organ transplantation
and hemodialysis; truth telling and confidentiality in medicine.
In short, what bioethics really concerned with is the establishment and maintenance of vital and moral human
relationships between the sick and the dying on the one hand, and the healthy and the medical professionals on the
other. It is concerned with “treatment” in the broadest sense; that is, it deals not only with how we treat patients in a
medical sense but also how we relate to, or deal with, our fellow human beings, especially in matters of illness,
injury, dying and death.

3.2. Historical Background

Since the beginning of human history, concern for medical ethics has been expressed in the form of laws, decrees,
assumptions and “oaths” prepared for or by physicians. Among the oldest of these are the Code of Hammurabi in
Babylonia (approximately 1750 BCE), Egyptian papyri, Indian and Chinese writings, and early Greek writers, most
notably Hippocrates (lived between 460 and 377 BCE).

Early medical ethical codes were written by individuals or by small groups of people, usually physicians. The Oath
of Hippocrates is considered historically to be the first such code written in an organized and logical way which
describes the proper relationships between physician and patient. During the Middle Ages, other medical codes were
written. In recent times, Thomas Precival’s writings, disseminated in 1803, represent one of the first ethical codes in
the United States and the Western world.

Beginning in the second half of the nineteenth century medical organizations began writing codes of medical ethics.
The first ethics code of the American Medical Association (AMA) was published in 1847. This was the first ethical
code of a professional organization which outlined the rights of patients and caregivers. Over the years many
revisions and additions to this original code have been made. The latest edition of the AMA Code of Medical Ethics
(1997) contains four parts, which include general principles, opinions on specific issues and special reports. The
AMA established the Council on Ethical and Judicial Affairs to advise it on legal and ethical issues and to prepare
position papers on these issues for the AMA. The British Medical Association published its first code of Medical
Conduct of Physicians in 1858. The code has subsequently undergone numerous changes. The World Health
Organization (WHO) issued the Declaration of Geneva in 1948. This is the first worldwide medical ethical code and
is modeled after the Oath of Hippocrates. Many other medical organizations throughout the world, including those
in Ethiopia, have issued medical ethical codes.

Modern medical ethics as a separate field began to develop in the 1950’s. One of the major innovations of modern
Western medical ethics involves the physician-patient relationship with the dramatic change from paternalism to
autonomy and its resultant requirement for informing the patient, obtaining informed consent, and relating to the
patient as an active partner in decision-making.

Modern medical ethics involves a wide range of topics which produce ethical dilemmas in the conduct of
physicians, other health professionals, patients, families and society in general.
Medical ethics may be divides into general biomedical ethics which deals with fundamental principles, societal
issues and policy determination, and clinical ethics which deals with the application of practical medical ethical
principles in the day-to-day care of patients.

Why medical ethics?

A number of reasons are responsible for the enormous recent interest in medical ethics:

(a) Significant technological and scientific advances and changes in clinical medicine and research have produced
totally new ethical dilemmas and exacerbated old ones.

(b) The change in philosophy from paternalism to autonomy in the physician-patient relationship has removed from
the physician the monopoly on decision-making.

(c) The involvement of additional caregivers (various medical specialists, a variety of health professionals, students,
administrators and investigators), each with their own cultural and social value systems, have increased and
sharpened ethical debates and discussions.

(d) The involvement of society at large (through the mass communication media, courts, legislators) has created the
necessity to redefine the societal parameters of the physician-patient and physician-societal relationship.

(e) Broad social changes throughout the world have damaged the image of the unique nobility of the physician. This
change has been enhanced by the commercialization of medical services and the greater sense of consumer criticism.
Moreover, in recent years physicians have come to view medicine more in terms of their careers, honor, self-
fulfillment and income. There is a call nowadays to return to the historic principles of the medical profession, which
differs from most other professions. Medicine should be viewed as service to the sick and the needy, with humility,
honesty, empathy, intellectual integrity, and effacement of self-interest.

The goals of medical ethics include the analysis of the relative merits of alternative actions in medical ethical
dilemmas. Definite and absolute decisions are not always attainable or implementable. Therefore, medical ethics is
satisfied with decisions defining the relationship between what is desirable and what is practical or in the choice of
the lesser of two evils. Medical ethics is generally pluralistic and multidisciplinary in its approach. Its main function
is to identify and characterize the component elements of a given medical situation and to provide an analytic
process for assessing and applying the relevant values and principles of ethics.

3.3. Medical Ethics, Medical Professionalism, Human Rights and Law

Ethics has been an integral part of medicine at least since the time of Hippocrates, the fifth century B.C.E. (before
the Christian era) Greek physician who is regarded as a founder of medical ethics. From Hippocrates came the
concept of medicine as a profession, whereby physicians make a public promise that they will place the interests of
their patients above their own interests.
In recent times medical ethics has been greatly influenced by developments in human rights. In a pluralistic and
multicultural world, with many different moral traditions, the major international human rights agreements can
provide a foundation for medical ethics that is acceptable across national and cultural boundaries.

Moreover, physicians frequently have to deal with medical problems resulting from violations of human rights, such
as forced migration and torture. And they are greatly affected by the debate over whether healthcare is a human
right, since the answer to this question in any particular country determines to a large extent who has access to
medical care.

Medical ethics is also closely related to law. In most countries there are laws that specify how physicians are
required to deal with ethical issues in patient care and research. In addition, the medical licensing and regulatory
officials in each country can and do punish physicians for ethical violations. But ethics and law are not identical.
Quite often ethics prescribes higher standards of behavior than does the law, and occasionally ethics requires that
physicians disobey laws that demand unethical behavior. Moreover, laws differ significantly from one country to
another while ethics is applicable across national boundaries.

“...often ethics prescribes higher standards of behavior than does the law, and occasionally ethics requires that
physicians disobey laws that demand unethical behavior.

3.4. Fundamental Ethical Principles in Medical Ethics

In recent years, several fundamental ethical principles have been formulated and widely adopted as the basis for
ethical discussion in medicine. A common framework used in the analysis of medical ethics is the "four principles"
approach postulated by Tom Beauchamp and James Childress. 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:

1. Respect for autonomy - the patient has the right to refuse or choose their treatment.

2. Non-maleficence - "first, do no harm"

3. Beneficence - a practitioner should act in the best interest of the patient.

4. Justice - concerns the distribution of scarce health resources, and the decision of who gets what treatment
(fairness and equality).

Dear students, let us discuss each of them.

Autonomy is defined as a fundamental principle based on the worldview that every person has intrinsic value. One
may not restrict nor negate the free wishes of an individual with respect to his own body. One must facilitate any
desired action acceptable to a person’s own judgment and in accordance with his own choice. The granting of
autonomy requires that we recognize and accept the free choice of each person even if that choice seems
inappropriate or foolish or even life-endangering.

A precondition for autonomy is complete freedom of the individual from outside control or pressure. Any action that
derives from external control which interferes with one’s expression of autonomy is termed heteronomy. By
definition proper, full autonomy cannot be exercised by the very young, the mentally retarded or the psychotic. Also
autonomy is not to be respected if such a choice is likely to harm others.

Many ethicists view autonomy as the most important ethical principle which supersedes all others. In recent years,
the tendency is to decide more and more medical ethical and legal dilemmas according to this principle. Other
ethicists view autonomy as only one of several important ethical principles.

Autonomy is not only the privilege of the patient. It is universally agreed that the physician’s autonomy, too, must
be respected. A physician may refuse a patient’s request for a therapy that has no scientific or rational basis,
especially if it may be harmful to the patient. Also, a physician may refuse to implement a patient’s decision for a
certain treatment if it conflicts with the physician’s conscience, for whatever reason. In such situations, the physician
has the right not to treat the patient and to transfer such care to another physician. A difficult question relates to very
expensive treatment requested by a terminally ill, incurably sick patient which could only minimally extend the
patient’s life. Some writers justify the physician’s autonomy in deciding against the patient’s autonomy whereas
others consider such action to be unjust.

The principle of autonomy is based on the Principle of Respect for Persons, which holds that individual persons
have right to make their own choices and develop their own life plan

Non-maleficence (primum non nocere) is defined as the obligation not to harm others and to remove and prevent
potential harm. Thus, one must not only prevent intentional harm but must also be appropriately cautious not to
cause harm. Health care workers must be properly trained so that they not inflict harm because of lack of knowledge
or lack of appropriate skills.

This concept of non-maleficence is applied to the relationship between physician and patient based upon the phrase
that “above all do no harm.” Some writers state that nowadays non-maleficence should be re-defined to strive not to
do harm, by balancing the benefit against the harm of any specific action. However, this ethical principle of not
doing harm should not be absolute and cannot be applied fully in all diagnostic and therapeutic interventions. The
cause for this change in the definition of non-maleficence relates to the major changes in the practice of medicine
today as compared to that practiced in antiquity.

The principle of non-maleficence requires us, other things being equal; to avoid harm to the patient, or what would
be against the patient’s interests.

Beneficence is defined as the moral obligation to do good for others, and to help them in an active way. Ethically, it
is not enough to avoid doing harm but one must actively do good to others. But, obviously there are limits to the
requirement that one act to help others at all times. These vary with the degree of need, the ease and ability with
which the help can be rendered, and the nature of the relationship between the individual needing help and the one
able to provide it.

The principle of beneficence requires us, other things being equal, to do good, or what will further the patient’s
interest.

Justice is the granting and fulfillment of legitimate rights of others, and injustice is their denial. Justice requires the
division of rights and assets in an equitable and appropriate manner, but no less so the fair distribution of duties and
burdens. In the simplistic sense, justice means equality. However, in daily life, many variables cause unequal
division of obligations and rights. Therefore, several ethical theories and techniques have been developed for
distributive justice, taking into consideration needs, rights, contributions to society, and other factors.

Different theories of justice place greater priority on different factors: Marxism emphasizes economic needs, while
liberalism emphasizes social needs. The differences in views and emphases make it difficult to attain ideal justice,
since equality in one aspect may bring inequality in another and, hence, injustice.

Individual rights became a cornerstone in political, legal and social thinking in the nineteenth century. Some believe
that people have absolute moral rights unrelated to changing social conditions. These include “natural” universal
rights such as the right to life, liberty and privacy. Others believe that rights flow from societal consensus, customs
and laws and therefore are relative and may change according to the circumstances.

The principle of justice is the principle that requires that we distribute goods and service, including medical goods
and services, fairly.

Activity 1. How are we to distribute expensive, scarce, medical services when not everyone can get what he or she
needs?

Why is it important to adhere to ethical principles in health and medical care?

The following are some of the importance of the application of ethical standards in health and medical care.

First, ethical standards promote the aim of medical care to alleviate suffering. For example, recruiting highly
qualified medical personnel and exposing them to continuous in-service training will promote their knowledge and
skills in both medical care and medical ethics, and may minimize errors. Second, medical care is built on the
communication between medical workers on one side and patients and/or patients’ families on another side. Ethical
standards promote the values that are essential to good communication, such as trust, accountability, mutual respect
and fair medical care. Many ethical standards in medical care, including informed consent, protection of privacy and
maintenance of confidentiality, provide a grantee for respect for persons. Third, ethical standards will help to build
public support for medical care. People are more likely to pay for medical care and donate to health promoting
projects if they trust the quality and integrity of these programmes.
Fourth, health and medical care typically involve different medical workers from a variety of disciplines. They need
to work in healthy work environments that are characterized by trust, accountability, mutual respect and fairness.
Ethical standards may promote the values of cooperation and collaborative work. Finally, ethical standards in
medical care promote other important moral and social values such as social responsibility, human rights, patients’
welfare, compliance with the law, and patients’ safety. Adherence to ethical standards can significantly facilitate a
pleasant environment for both patients and medical workers.

Does a Medical ethic differ from One Country to Another?

Just as medical ethics can and does change over time, in response to developments in medical science and
technology as well as in societal values, so does it vary from one country to another depending on these same
factors. On euthanasia, for example, there is a significant difference of opinion among national medical associations.
Some associations condemn it but others are neutral and at least one, the Royal Dutch Medical Association, accepts
it under certain conditions. Likewise, regarding access to healthcare, some national associations support the equality
of all citizens whereas others are willing to tolerate great inequalities. In some countries there is considerable
interest in the ethical issues posed by advanced medical technology whereas in countries those do not have access to
such technology, these ethical issues do not arise.

Physicians in some countries are confident that they will not be forced by their government to do anything unethical
while in other countries it may be difficult for them to meet their ethical obligations, for example, to maintain the
confidentiality of patients in the face of police or army requirements to report ‘suspicious’ injuries.

Although these differences may seem significant, the similarities are far greater. Physicians throughout the world
have much in common, and when they come together in organizations such as the World Medical Association, they
usually achieve agreement on controversial ethical issues, though this often requires lengthy debate. The
fundamental values of medical ethics, such as compassion, competence and autonomy, along with physicians’
experience and skills in all aspects of medicine and healthcare, provide a sound basis for analyzing ethical issues in
medicine and arriving at solutions that are in the best interests of individual patients and citizens and public health in
general.

LESSON TWO: RIGHTS AND OBLIGATIONS OF HEALTH CARE PROFESSIONALS AND PATIENTS
AND THEIR FAMILIES

This section attempts to address rights and obligations expected from the patients, their families and health care
professionals.

Health care professionals are doctors, nurses and attendants or aides, therapists, technicians and all others involved
in medical aid.

What are the rights and obligations of health care professionals, patients and their families?
There are three views of what the relationship between health care professionals and patients and their families
should be. They are paternalism, radical individualism and collegial view.

1. PATERNALISM

Paternalism is the position that health care professionals should take a parental role towards patients and their
families. According to this position, professionals have a superior knowledge of medicine; therefore they and they
alone are privileged because of their long and specialized training to decide what is best for patients and their
families. This attitude is characterized by the old cliché “The doctor always knows best.”

Do you support Paternalism featured with dictum “The doctor always knows best.” Why or why not?

There are a number of arguments that are forwarded to support paternalism viewpoint.

First of all, lay people lack the professional knowledge of medicine to deal with both physical and mental illness and
injury. As a result they have no way of knowing what is best for them.

Second, because of their long, hard professional education and because of their experience professionals (especially
doctors) know the characteristics of diseases and injuries; therefore, patients should place themselves totally in the
professionals’ hands.

Finally, any and all decisions about patients’ care and treatment, including the information that should be given them
and decisions concerning hospitalization, tests and so on, should be completely in the hands of the doctors and their
professional assistants. Patients must trust them and not interfere with the treatment suggested.

2. RADICAL INDIVIDUALISM

Radical individualism is the position that patients have absolute right over their own bodies and lives and therefore
may reject all recommendations of health care personnel (especially doctors).

Do you support this position? Why or why not?

There are a number of arguments supporting this position. First, doctors are human like everybody else, and they are
capable of errors in judgments, diagnosis, prognosis and treatment. They are even at times guilty of malpractice,
negligence or maltreatment.

Second, patients (or their families when patients are totally incapacitated) are best qualified to decide if, hoe, when
and what treatment is to be given; after all, their bodies and life are at stake, not those of the professionals.

Third, many issues having to do with treatment are not strictly medical, and professionals sometimes are not
qualified to make appropriate decisions concerning such issues ( for example at what point debilitating, painful
treatment should be stopped because its negative effects outweigh any curative power it may have).
Fourth, these das lay people are better educated about their bodies and minds and about the illness and injuries that
affect them. They are also able to understand their medical condition, diagnoses and prognoses if professionals will
only have the kindness and courtesy to explain things to them clearly an in plain language.

Finally, paternalism has often led to total patient dependence and sometimes to complete dehumanization, when a
patient is regarded merely as living body to be investigated, analyzed, medicated or operated on without recognition
that a person still resides within it.

3. THE RECIPROCAL, OR COLLEGIAL, VIEW

In this view, patients and their families are key members of the team, and doctors, nurses and other health care
professionals work together to do what is best for patients and their families.

This position is supported by a number of arguments, some of which are similar to those for individualism.

First, professionals, particularly doctors, are neither gods nor valid father figures; rather, they are human beings with
specialized education, training and experience, which makes them an important element in the care of patients and
their families.

Second, many of the decisions concerning the treatment of patients and their families are not strictly medical in
nature and therefore should not be made solely by medical professionals. Doctors need to rely on other health care
personnel such as nurses; psychiatric, physical and occupational therapists. They also need the support of
nonmedical personnel such as clergy, social workers and trained volunteers if they are to properly treat patients and
their families as whole human beings rather than medical specimens.

Third, it is important to recognize the rights of individual patients to make free choices concerning their treatment
because it is their bodies and lives that are at stake. These rights are not “absolute” but they are and should be given
high priority. In addition to the right to participate actively in decisions regarding medical care, including the right to
refuse treatment, patients also have the right to considerate and respectful care; information about their diagnoses,
treatment and prognoses; full knowledge about human experimentation and the right to refuse.

All of this means that neither patients nor professionals alone “know best” but that decisions involving care and
treatment are to be reciprocal (that is, involving give and take) and collegial (that is, involving a group or team
approach in which each member has equal input) rather than dictatorial, paternalistic or anarchistic.

Obviously professionals do “know best” in certain areas, but they should share their information and expertise with
their patients and their families. Patients must realize, however, that no matter how well informed they are, they
can’t know everything about medicine and they must defer to professionals in some areas. According to reciprocal
or collegial view, all decisions should be arrived at through a free exchange of ideas and a full decision of alternative
methods of care and treatment, with final decisions being made jointly by patients or their families (when patients
are incapacitated) and their doctors.
In other words, collegial care calls for proper, intelligent and informed communication between patients and their
doctors. Doctors can facilitate such communication.

2.2. TRUTH TELLING AND INFORMED CONSENT IN MEDICINE

What does truth telling and informed consent mean in medical profession?

The issue involving truth telling is to what extent patients and their families should be told the truth about their
illnesses, injuries and/ or dying. The term informed consent refers to a formalized procedure whereby patients (or
family members, when patients are incapacitated) “consent,” usually in writing, to some sort of medical treatment,
procedure, or surgery that may have questionable side effects, affect patients’ future lives, or even involve the risk
the death.

2.2.1. Truth Telling

There are three views of truth telling in medicine. These are the paternalistic view, that of the patients’ right to know
and the moderate position.

A.The Paternalistic View of Truth Telling

There are several arguments put forth to support the paternalistic viewpoint.

First, because patients are not medically trained, they cannot understand what doctors tell them; therefore, they do
not need to know more than the fact that professionals are doing their very best for them. Second, it is best both for
patients’ morale and for their will to get better or will to live if they are not told the truth, especially if it is bad news,
because full of their situation might cause them to “lose heart” and not fight to survive. Third, it would serve no
purpose to give them bad news, because if the prognosis is that they are going to die, for example, they will die
anyway; therefore, one should let them live out the time they have left as happily as they can. Fourth, it is all right to
tell the families but not the patients – patients should be protected from bad news. Finally, it is important for the
doctor, nurse and other professionals as well as the family members to avoid “being morbid” and discussing the
seriousness of patients’ illnesses, injuries or dying with them. Everyone connected with patients should try to cheer
them up and deny bad news whenever possible.

B.The Patients’ Right to Know

There are a number of arguments supporting the patients’ right to know, many of them criticisms of the paternalistic
arguments. First, because it is the patients’ bodies and lives that are involved, not those of the professionals or even
other family members, patients have a right to know everything and should be told all.

Second, it is much easier to treat and deal with patients if they are aware o what is going on and if professionals and
family members do not have to constantly pretend that patients’ illnesses or injuries are not serious or that patients
are not dying.
Third, patients are often angry if they do not know about side effects or other painful or disturbing aspects of
treatment.

What do you think is the limitation of this position?

One negative aspect of the patients’ rights position is that some professionals adopt this view so fervently that they
are brutally rank with their patients, often leaving them without any hope or frightening them unnecessarily.

C.The Moderate Position

This view lies between paternalism and brutal frankness. It is a sharing of appropriate information with patients
when they want to know it and to the extent they want to know it. This view lets patients be the guide in determining
the information they will receive. It involves the following aspects:

1. Listening to patients carefully and hearing what they are really asking or trying to ask.

2. Not avoiding persistent, roundabout, or direct questions but rather answering them truthfully, yet not brutally.

3. Not forcing information on patients when they are not ready just because the professional is ready to discuss the
matter or is too busy to wait until patients are ready.

4. Not avoiding the truth by using medical and technical language or jargon, but trying instead to explain everything
patients want to know in lay terms.

5.Being aware that explanations or answers may have to be given in gradual doses or more than once because
human beings will often defend themselves against the shock of bad news by not really “hearing” what is being said.

6. Always telling the truth clearly, gently, and humanly, never brutally, coldly, hopelessly, or cruelly.

7.Never leaving patients and their families without some hope, even if it is only that professionals will keep trying to
do the very best they can to care patients and to keep them comfortable and out of pain.

2.2.2. Informed Consent

As we have tried to mentioned, informed consent is a more formalized approach to truth telling and to involving
patients in decisions concerning their treatment. This approach is necessary in our time because of the many
complex technological tests, procedures and surgeries required, not only for individual therapeutic reasons, but also
for experiments that can help science benefit (for example, by testing reactions to new drugs).

The assumption behind the “informed consent” approach is that in order to intelligently “consent” to a procedure,
patients must be fully “informed”; furthermore, they must agree in writing to undergo the procedure in order to
avoid any later confusions and legal complications that may arise from such procedures. In order to facilitate the
informed consent procedure, many hospitals and laboratory groups have printed informed consent forms for patients
to read and sign. These forms should do the following: explain the procedure and its purpose clearly and in ordinary
language; explain what kinds of discomfort or pain the procedure will cause patients to feel before, during and after
its completion; explain any and all complications that may arise because of the procedure; state how long the
procedure will take; include a statement that the patient’s doctors have judged that the procedures should be
performed, for the patients best interests and welfare and despite any discomforts or risks.

The best approach in getting informed consent is for the physician who is requiring or performing the procedure to
explain it in some detail in addition to having the patients read the form. Patients and their families should also be
encouraged to ask any questions they wish, and should be given honest and clear answers. The idea behind such
verbal explanations is that when patients sign this forms it is important that they have truly been fully informed;
merely reading a paper is often not enough, especially when [patients are confused; worried or even scared for the
procedure.

2.2.3. Doctors’ Reaction to Truth Telling and Informed Consent

Some doctors are generally opposed to full disclosure of truth to the patients and are also opposed to informed
consent, except as a mere formality. The following are some of the reasons.

First of all, such doctors feel that patients do not need to be fully informed because doctors know what they are
doing and explanations of complicated medical procedures will only confuse patients and break down the
relationship of faith and trust that should exist between doctor and patient. Second, patients often don’t want to hear
explanations, and focusing them to against their wills is an invasion of their rights. Third, every procedure has its
risks, but there is no reason to frighten patients unnecessarily when chances are only, for example, two in one
hundred thousand that a particular allergy or side effect will occur. Fourth, such explanations may unnecessarily
frighten patients to the extent that they will refuse to undergo a procedure that may be necessary to their health.

Finally, doctors sometimes feel that by describing certain side effects, such as, headaches, for example, they can
induce such problems through the power of suggestion. The other extreme in truth telling is to go overboard and
“tell all”. Some doctors feel that it is important that patients know every “sordid” detail of what is going to happen
to them, whether they want to or not. But it would seem that giving information to such an extent serves no purpose
unless the patient insists on knowing every last detail, which very few would. Except in such cases, overly detailed
explanations merely cause unnecessary anxiety.

2.2.4. Patients’ and Families’ Reaction to Truth Telling

As mentioned in the preceding section, some doctors base decisions concerning what information to give on
sensitivity to what patients and their families want to know. It is certainly true that many patients and families don’t
want to know the truth; they prefer to deny that “terrible things” are happening to them. However, most patients
want to know what is happening to because it is their bodies and lives that are at risk. Perhaps they don’t want or
need to know all the details but they do want to know the crucial facts.
Furthermore, just because patients and their families sometimes want to deny the existence of serious illness, injury,
ding and death, doesn’t necessarily mean they don’t really want to know the truth. After all, there is often
“unfinished business” that can be accomplished if the truth is faced: dealing with inheritance and wills, settling
family feuds, resolving other relationship problems and doing things families have always wanted to do but have put
off. If patients and their families are not told the truth, they can miss an important opportunity to put their lives in
order.

2.3. Confidentiality

Confidentiality in patient-doctor relationship would on the surface seem to be fairly clear that is, whatever the doctor
and patient discuss and whatever the patient reveals in this relationship is to be held in strictest confidence, just as
in other professions like the lawyer-client or priest/minister- parishioner relationships. And, generally, that clarity
holds true, but confidentiality is not always a clear-cut issue in the doctor-patient one. For example, what happens
when a doctor tests a patient for a sexually transmitted diseases including AIDS?

Why do you think that AIDS results are reported anonymously?

Activity: considers the following two cases, and discuss and attempt to give your own rational justification on
each.

Case 1: Divided Loyalties.

Imagine that you are a physician and one of your patients is a four-year-old girl in sever renal failure. She is failing
to thrive on dialysis and it has become evident that without a kidney transplant in the near future she will not
survive. The chance of a successful transplant is roughly ninety percent if the kidney comes from a close relative
whose tissue type is virtually identical to that of the recipient. A successful transplant is far less probable if the tissue
match is less close, even if the kidney is from a near relative. And implanting a poorly matched kidney from a
relative holds out no greater probability of success than the implantation of an equally poor match from a cadaver.
The probability of getting a good tissue match form a cadaver is lower than getting one from within the family. You
inform the child’s family (her parents and two older siblings) of this; all agree to undergo tissue-typing to see if any
of the family members are good candidates for donation.

The tests reveal that the child’s father is an excellent match. All the other family members are poor matches. You
are about to contact the family with the good news when the father arrives and asks to speak with you about the test
results. You tell him, but much to your surprise, he begins to cry and tells you that he is afraid to denote his kidney.
He begs you to tell his family that none of them is an appropriate tissue match and asks you to begin the search for a
cadaver kidney. The child’s best chance for survival lies in receiving a kidney from her father. You feel quite certain
that if you tell the man’s wife, he will be shamed into denoting. What should you do? On the basis of what
considerations should you make your decision?
 Case 2: the Nurse’s dilemma

Imagine now that you are a nurse on a medical/surgical floor in a large private hospital. A woman is admitted on a
Sunday for series medical tests. You are assigned as her primary nurse. The testing begins on Monday and you are
off for the next few days. You return to work the following Saturday and resume your duties as the woman’s
primary nurse. When you arrive on the floor, you go over her chart and find that the tests have revealed she has
chronic lymphocytic leukemia and is being transfused in an attempt to put the disease into remission. As you
approach her that morning, she greets you happily and asks if you know when she will be able to return to work.
Given her diagnoses, you are a bit puzzled by her exuberance and you judiciously reply that you have not seen her
physician since your return to work but you will talk with the physician about her discharge form the hospital.

On your way back to the nurses’ station, one of the woman’s two daughters approaches you and urges you to assure
her mother that there is no reason for concern. The daughter tells you her mother has just been through a painful
divorce and that she and her sister have decided her mother should not be burdened with the news that she has a
terminal illness. You discuss the whole situation with your head nurse. She tells you to talk with the woman’s
physician, who is also the new director of the hospital’s medical service. You avoid going to the woman’s room
until the physician arrive on the floor. When she arrives, you tell her about the woman’s request for information
regarding her discharge and about your conversation with the daughter. The physician informs you that the woman
has been told simply that she has refractory anemia (which, in fact, is a result of the leukemia) and has not been told
the true nature of her illness in order to spare unnecessary anxiety.

You protest that the woman does not seem mentally unsound in any way and, therefore, she has a right to know
about her diagnosis and prognosis. But the physician interrupts you and says that further disclosure on your part
would have to be considered inconsistent with the best medical care of this woman. You are deeply troubled and
return to your head nurse, who sis sympathetic but advise you to follow the physician’s direction. She also says if
this sort of thing really bothers you, she will be careful to assign this physician’s patients to someone else in the
future. What should you do? On the basis of what consideration should you make your decision?

2.4. Physicians and Society

2.4.1. What’s Special about the Physician-Society Relationship?

Medical professionalism involves not just the relationship between a physician and a patient, as discussed in the
preceding section, and relationships with colleagues and other health professionals. It also involves a relationship
with society. This relationship can be characterized as a ‘social contract’ whereby society grants the profession
privileges, including exclusive or primary responsibility for the provision of certain services and a high degree of
self-regulation, and in return, the profession agrees to use these privileges primarily for the benefit of others and
only secondarily for its own benefit.
Medicine is today, more than ever before, a social rather than a strictly individual activity. It takes place in a context
of government and corporate organization and funding. It relies on public and corporate medical research and
product development for its knowledge base and treatments. It requires complex healthcare institutions for many of
its procedures. It treats diseases and illnesses that are as much social as biological in origin.

The Hippocratic tradition of medical ethics has little guidance to offer with regard to relationships with society. To
supplement this tradition, present-day medical ethics addresses the issues that arise beyond the individual patient-
physician relationship and provides criteria and processes for dealing with these issues.

Physicians have various relationships with society. Because societies, and its physical environment, are important
factors in the health of patients, both the medical profession in general and individual physicians have significant
roles to play in public health, health education, environmental protection, laws affecting the health or well-being of
the community, and testimony at judicial proceedings.

As the World Medical Association (WMA) Declaration on the Rights of the Patient puts it: “Whenever legislation,
government action or any other administration or institution denies patients [their] rights, physicians should pursue
appropriate means to assure or to restore them.” Physicians are also called upon to play a major role in the allocation
of society’s scarce healthcare resources, and sometimes they have a duty to prevent patients from accessing services
to which they are not entitled. Implementing these responsibilities can raise ethical conflicts, especially when the
interests of society seem to conflict with those of individual patients.

Dual Loyalty

When physicians have responsibilities and are accountable both to their patients and to a third party and when these
responsibilities and accountabilities are incompatible, they find themselves in a situation of ‘dual loyalty’. Third
parties that demand physician loyalty include governments, employers (e.g., hospitals and managed healthcare
organizations), insurers, military officials, police, prison officials and family members. Although the WMA
International Code of Medical Ethics states that “A physician shall owe his/her patients complete loyalty,” it is
generally accepted that physicians may in exceptional situations have to place the interests of others above those of
the patient. The ethical challenge is to decide when and how to protect the patient in the face of pressures from third
parties.

Dual loyalty situations comprise a spectrum ranging from those where society’s interests should take precedence to
those where the patient’s interests are clearly paramount. In between is a large grey area where the right course of
action requires considerable discernment. At one end of the spectrum are requirements for mandatory reporting of
patients who suffer from designated diseases, those deemed not fit to drive or those suspected of child abuse.
Physicians should fulfill these requirements without hesitation, although patients should be informed that such
reporting will take place.
At the other end of the spectrum are requests or orders by the police or military to take part in practices that violate
fundamental human rights, such as torture. In its 2003 Resolution on the Responsibility of Physicians in the
Denunciation of Acts of Torture or Cruel or Inhuman or Degrading Treatment of which They are Aware, the WMA
provides specific guidance to physicians who are in this situation. In particular, physicians should guard their
professional independence to determine the best interests of the patient and should observe, as far as possible, the
normal ethical requirements of informed consent and confidentiality. Any breach of these requirements must be
justified and must be disclosed to the patient. Physicians should report to the appropriate authorities any unjustified
interference in the care of their patients, especially if fundamental human rights are being denied. If the authorities
are unresponsive, help may be available from a national medical association, the WMA and human rights
organizations.

Closer to the middle of the spectrum are the practices of some managed healthcare programmes that limit the
clinical autonomy of physicians to determine how their patients should be treated. Although such practices are not
necessarily contrary to the best interests of patients, they can be, and physicians need to consider carefully whether
they should participate in such programmes. If they have no choice in the matter, for example, where there are no
alternative programmes, they should advocate vigorously for their own patients and, through their medical
associations, for the needs of all the patients affected by such restrictive policies.

A particular form of a dual loyalty issue faced by physicians is the potential or actual conflict of interest between a
commercial organization on the one hand and patients and/or society on the other. Pharmaceutical companies,
medical device manufacturers and other commercial organizations frequently offer physicians gifts and other
benefits that range from free samples to travel and accommodation at educational events to excessive remuneration
for research activities. A common underlying motive for such company largesse is to convince the physician to
prescribe or use the company’s products, which may not be the best ones for the physician’s patients and/or may add
unnecessarily to a society’s health costs. The WMA’s 2004 Statement Concerning the Relationship between
Physicians and Commercial Enterprises provides guidelines for physicians in such situations and many national
medical associations have their own guidelines. The primary ethical principle underlying these guidelines is that
physicians should resolve any conflict between their own interests and those of their patients in their patients’
favour.

Resource allocation

In every country in the world, including the richest ones, there is an already wide and steadily increasing gap
between the needs and desires for healthcare services and the availability of resources to provide these services. The
existence of this gap requires that the existing resources be rationed in some manner. Healthcare rationing, or
‘resource allocation’ as it is more commonly referred to, takes place at three levels:

(1)At the highest (‘macro’) level, governments decide how much of the overall budget should be allocated to health;
which healthcare expenses will be provided at no charge and which will require payment either directly from
patients or from their medical insurance plans; within the health budget, how much will go to remuneration for
physicians, nurses and other health care workers, to capital and operating expenses for hospitals and other
institutions, to research, to education of health professionals, to treatment of specific conditions such as tuberculosis
or AIDS, and so on.

(2)At the institutional (‘meso’) level, which includes hospitals, clinics, healthcare agencies, etc., authorities decide
how to allocate their resources: which services to provide; how much to spend on staff, equipment, security, other
operating expenses, renovations, expansion, etc.

(3) At the individual patient (‘micro’) level, healthcare providers, especially physicians, decide what tests should be
ordered, whether a referral to another physician is needed, whether the patient should be hospitalized, whether a
brand-name drug is required rather than a generic one, etc. It has been estimated that physicians are responsible for
initiating 80% of healthcare expenditures, and despite the growing encroachment of managed care, they still have
considerable discretion as to which resources their patients will have access.

The choices that are made at each level have a major ethical component, since they are based on values and have
significant consequences for the health and well-being of individuals and Communities. Although individual
physicians are affected by decisions at all levels, they have the greatest involvement at the micro-level. Accordingly,
this will be the focus of what follows.

As noted above, physicians were traditionally expected to act solely in the interests of their own patients, without
regard to the needs of others. Their primary ethical values of compassion, competence and autonomy were directed
towards serving the needs of their own patients. This individualistic approach to medical ethics survived the
transition from physician paternalism to patient autonomy, where the will of the individual patient became the main
criterion for deciding what resources he or she should receive. More recently, however, another value, justice, has
become an important factor in medical decision-making. It entails a more social approach to the distribution of
resources, one that considers the needs of other patients. According to this approach, physicians are responsible not
just for their own patients but, to a certain extent, for others as well.

This new understanding of the physician’s role in allocating resources is expressed in many national medical
association codes of ethics and, as well, in the WMA Declaration on the Rights of the Patient, which states: “In
circumstances where a choice must be made between potential patients for a particular treatment that is in limited
supply, all such patients are entitled to a fair selection procedure for that treatment. That choice must be based on
medical criteria and made without discrimination.”

A type of allocation decision that many physicians must make is the choice between two or more patients who are
in need of a scarce resource such as emergency staff attention, the one remaining intensive care bed, and organs for
transplantation, high-tech radiological tests, and certain very expensive drugs. Physicians who exercise control over
these resources must decide which patients will have access to them and which will not, knowing full well that those
who are denied may suffer, and even die, as a result. Some physicians face an additional conflict in allocating
resources, in that they play a role in formulating general policies that affect their own patients, among others.

“One way that

In dealing with these allocation issues, physicians must not only balance the principles of compassion and justice
but, in doing so, must decide which approach to justice is preferable. There are several such approaches, including
the following:

• libertarian – resources should be distributed according to market principles (individual choice conditioned by
ability and willingness to pay, with limited charity care for the destitute);

• utilitarian – resources should be distributed according to the principle of maximum benefit for all;

• egalitarian – resources should be distributed strictly according to need;

• restorative – resources should be distributed so as to favors the historically disadvantaged.

As noted above, physicians have been gradually moving away from the traditional individualism of medical ethics,
which would favors the libertarian approach, towards a more social conception of their role. Even if the libertarian
approach is generally rejected, however, medical ethicists have reached no consensus on which of the other three
approaches is superior. Each one clearly has very different results when applied to the issues mentioned above, that
is, deciding what tests should be ordered, whether a referral to another physician is needed, whether the patient
should be hospitalized, whether a brand-name drug is required rather than a generic one, who gets the organ for
transplantation, etc.

The utilitarian approach is probably the most difficult for individual physicians to practise, since it requires a great
deal of data on the probable outcomes of different interventions, not just for the physician’s own patients but for all
others. The choice between the other two (or three, if the libertarian is included) will depend on the physician’s own
personal morality as well as the socio-political environment in which he or she practises. Some countries, such as
the U.S.A., favour the libertarian approach; others, e.g., Sweden, are known for their egalitarianism; while still
others, such as South Africa, are attempting a restorative approach. Many health planners promote utilitarianism.
Despite their differences, two or more of these concepts of justice often coexist in national health systems, and in
these countries physicians may be able to choose a practice setting (e.g., public or private) that accords with their
own approach.

In addition to whatever roles physicians may have in allocating existing healthcare resources, they also have a
responsibility to advocate for expansion of these resources where they are insufficient to meet patient needs. This
usually requires that physicians work together, in their professional associations, to convince decision makers in
government and elsewhere of the existence of these needs and how best to meet them, both within their own
countries and globally.

Public health

20th century medicine witnessed the emergence of an unfortunate division between ‘public health’ and other
healthcare (presumably ‘private’ or ‘individual’ health). It is unfortunate because, as noted above, the public is made
up of individuals, and measures designed to protect and enhance the health of the public result in health benefits for
individuals.

Confusion also arises if ‘public health’ is taken to mean ‘publicly funded healthcare’ (i.e., healthcare funded through
a country’s taxation system or a compulsory universal insurance system) and seen as the opposite of ‘privately-
funded healthcare’ (i.e., healthcare paid for by the individual or through private health insurance and usually not
universally available).

The term ‘public health’, as understood here, refers both to the health of the public and also to the medical specialty
that deals with health from a population perspective rather than on an individual basis. There is a great need for
specialists in this field in every country to advise on and advocate for public policies that promote good health as
well as to engage in activities to protect the public from communicable diseases and other health hazards. The
practice of public health (sometimes called ‘public health medicine’ or ‘community medicine’) relies heavily for its
scientific basis on epidemiology, which is the study of the distribution and determinants of health and disease in
populations. Indeed, some physicians go on to take extra academic training and become medical epidemiologists.
However, all physicians need to be aware of the social and environmental determinants that influence the health
status of their individual

patients. As the WMA Statement on Health Promotion notes: “Medical practitioners and their professional
associations have an ethical duty and professional responsibility to act in the best interests of their patients at all
times and to integrate this responsibility with a broader concern for and involvement in promoting and assuring the
health of the public.”

Public health measures such as vaccination campaigns and emergency responses to outbreaks of contagious diseases
are important factors in the health of individuals but social factors such as housing, nutrition and employment are
equally, if not more, significant. Physicians are seldom able to treat the social causes of their individual patients’
illnesses, although they should refer the patients to whatever social services are available. However, they can
contribute, even if indirectly, to long-term solutions to these problems by participating in public health and health
education activities, monitoring and reporting environmental hazards, identifying and publicizing adverse health
effects from social problems such as abuse and violence, and advocating for improvements in public health services.
Sometimes, though, the interests of public health may conflict with those of individual patients, for example, when a
vaccination that carries a risk of an adverse reaction will prevent an individual from transmitting a disease but not
from contracting it, or when notification is required for certain contagious diseases, for cases of child or elder abuse,
or for conditions that may render certain activities, such as driving a car or piloting an aircraft, dangerous to the
individual and to others. These are examples of dual-loyalty situations as described above.

In general, physicians should attempt to find ways to minimize any harm that individual patients might suffer as a
result of meeting public health requirements. For example, when reporting is required, the patient’s confidentiality
should be protected to the greatest extent possible while fulfilling the legal requirements.

A different type of conflict between the interests of individual patients and those of society arises when physicians
are asked to assist patients to receive benefits to which they are not entitled, for example, insurance payments or
sick-leave. Physicians have been vested with the authority to certify that patients have the appropriate medical
condition that would qualify them for such benefits. Although some physicians are unwilling to deny requests from
patients for certificates that do not apply in their circumstances, they should rather help their patients find other
means of support that do not require unethical behavior.

Global Health

The recognition that physicians have responsibilities to the society in which they live has been expanded in recent
years to include a responsibility for global health. This term has been defined as health problems, issues and
concerns that transcend national boundaries that may be influenced by circumstances or experiences in other
countries, and that are best addressed by cooperative actions and solutions. Global health is part of the much larger
movement of globalization that encompasses information exchange, commerce, politics, tourism and many other
human activities.

The basis of globalization is the recognition that individuals and societies are increasingly interdependent. This is
clearly evident with regard to human health, as the rapid spread of diseases such as influenza. Such epidemics
require international action for their control. The failure to recognize and treat highly contagious diseases by a
physician in one country can have devastating effects on patients in other countries. For this reason, the ethical
obligations of physicians extend far beyond their individual patients and even their communities and nations.

The development of a global view of health has resulted in an increasing awareness of health disparities throughout
the world. Despite large scale campaigns to combat premature mortality and debilitating morbidity in the poorest
countries, which have resulted in certain success stories such as the elimination of smallpox and (hopefully) polio,
the gap in health status between high and low-income countries continues to widen. This is partly due to HIV/AIDS,
which has had its worst effects in poor countries, but it is also due to the failure of low-income countries to benefit
from the increase in wealth that the world as a whole has experienced during the past decades.
Although the causes of poverty are largely political and economic and are therefore far beyond the control of
physicians and their associations, physicians do have to deal with the ill-health that is the result of poverty. In low-
income countries physicians have few resources to offer these patients and are constantly faced with the challenge of
allocating these resources in the fairest way. Even in middle- and high-income countries, though, physicians
encounter patients who are directly affected by globalization, such as refugees, and who sometimes do not have
access to the medical coverage that citizens of those countries enjoy.

Another feature of globalization is the international mobility of health professionals, including physicians. The
outflow of physicians from developing to highly industrialized countries has been advantageous for both the
physicians and the receiving countries but not so for the exporting countries. The WMA, in its Ethical Guidelines for
the International Recruitment of Physicians, states that physicians should not be prevented from leaving their home
or adopted country to pursue career opportunities in another country. It does, however, call on every country to do
its utmost to educate an adequate number of physicians, taking into account its needs and resources, and not to rely
on immigration from other countries to meet its need for physicians.

Physicians in the industrialized countries have a long tradition of providing their experience and skills to developing
countries. This takes many forms: emergency medical aid coordinated by organizations such as the Red Cross and
Red Crescent Societies and Médecins sans Frontiers’, short-term surgical campaigns to deal with conditions such as
cataracts or cleft palates, visiting faculty appointments in medical schools, short- or long-term medical research
projects, provision of medicines and medical equipment, etc. Such programmes exemplify the positive side of
globalization and serve to redress, at least partially, the movement of physicians from poorer to wealthier countries.

Activities

1. Discuss conflicts between the physician’s obligations to patients and to society and identify reasons for the
conflict.

2. Identify and deal with the ethical issues involved in allocating scarce medical resources.

3. Discuss physician responsibilities to public and global health.

Unit Summery

Medical ethics in the modern sense refers to the application of general and fundamental ethical principles to clinical
practice situations, including medical research. Individuals from various disciplines may author these principles. In
recent years, the term has been modified to biomedical ethics which includes ethical principles relating to all
branches of knowledge about life and health.

Bioethics is concerned with the establishment and maintenance of vital and moral human relationships between the
sick and the dying on the one hand, and the healthy and the medical professionals on the other. It is concerned with
“treatment” in the broadest sense.
Several fundamental ethical principles have been formulated and widely adopted as the basis for ethical discussion
in medicine. The four principles are: Respect for autonomy, Non-maleficence, Beneficence and Justice.

There are three views of what the relationship between health care professionals and patients and their families
should be. They are paternalism, radical individualism and collegial view.

Medical professionalism involves not just the relationship between a physician and a patient, and relationships with
colleagues and other health professionals. It also involves a relationship with society. This relationship can be
characterized as a ‘social contract’. Physicians have various relationships with society. Physicians are also called
upon to play a major role in the allocation of society’s scarce healthcare resources, and sometimes they have a duty
to prevent patients from accessing services to which they are not entitled. Implementing these responsibilities can
raise ethical conflicts, especially when the interests of society seem to conflict with those of individual patients.

Check list

Dear learners, by this time you have to answer the following questions.

Define what medical ethics is.

What does bioethics mean?

What is the difference between paternalism, radical individualism and collegial position?

What is informed consent? What is truth telling and confidentiality?

Mention some of ethical conflicts that rise when the physician discharges his/her responsibilities to the society.