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. These four values are not ranked in order of importance or relevance and 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. Both The Declaration of Helsinki (1964) and The Nuremberg Code (1947) are two well-known and well respected documents contributing to medical ethics. Beyond these milestones, both the development of hemodialysis in the 1960's and the overturning of Roe v. Wade by the Supreme Court in 2022 made an impact on the history of medical ethics. In 1973, Roe v. Wade was passed and became legal under the Constitution of the United States. However, now the States hold the power to impose their own laws on access to abortion services. This reversal causes a conflict with moral judgment if a doctor should be legally punished for providing an abortion to save a patient's life. In the beginning stages of hemodialysis, initial concerns arose about the ethical reasoning behind choosing which patients were a priority in using hemodialysis due to the scarcity of equipment. These concerns evolved from scarcity to the dilemma of the contentious practice with patients who lack the decision-making mentality. Whether doctors should abandon treatment because of their behavioral issues, disregarding their life-or-death situations.

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.

Medical ethics is also related to the law. But ethics and law are not identical concepts. More often than not, ethics implies a higher standard of behavior than the law dictates.

History

thumb|upright|A 12th-century [[Byzantine empire|Byzantine manuscript of the Hippocratic Oath]]

thumb|upright|AMA Code of Medical EthicsThe 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 by the American Medical Association in 1847, relying heavily on Percival's words. Over the years in 1903, 1912, and 1947, revisions have been made to the original document. 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:

  • Albert Kligman's dermatology experiments
  • Deep sleep therapy
  • Doctors' Trial
  • Greenberg v. Miami Children's Hospital Research Institute
  • Henrietta Lacks
  • Chester M. Southam's Cancer Injection Study
  • Human radiation experiments
  • Jesse Gelsinger
  • Moore v. Regents of the University of California
  • Surgical removal of body parts to try to improve mental health
  • Medical Experimentation on Black Americans
  • Milgram experiment
  • Radioactive iodine experiments
  • The Monster Study
  • Plutonium injections
  • The David Reimer case
  • The Stanford Prison Experiment
  • Tuskegee syphilis experiment
  • Willowbrook State School
  • Yanomami blood sample collection
  • Darkness in El Dorado
  • Erlanger baby

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.

COVID-19

In December 2019, the virus COVID-19 emerged as a threat to worldwide public health and, over the following years, ignited novel inquiry into modern-age medical ethics. For example, since the first discovery of COVID-19 in Wuhan, China, and subsequent global spread by mid-2020, calls for the adoption of open science principles dominated research communities. Some academics believed that open science principles — like constant communication between research groups, rapid translation of study results into public policy, and transparency of scientific processes to the public — represented the only solutions to halt the impact of the virus. Others, however, cautioned that these interventions may lead to side-stepping safety in favor of speed, wasteful use of research capital, and creation of public confusion. — as well as a type of vaccine hesitancy specifically due to the speed at which COVID-19 vaccines were created and made publicly available. However, open science also allowed for the rapid implementation of life-saving public interventions like wearing masks and social distancing, the rapid development of multiple vaccines and monoclonal antibodies that have significantly lowered transmission and death rates, and increased public awareness about the severity of the pandemic as well as explanation of daily protective actions against COVID-19 infection, like hand washing.

  • Lack of PPE for providers, putting them at increased risk of infection during patient care.
  • Heavy burden on healthcare providers and essential workers during entirety of pandemic
  • Closure of schools and increase in virtual schooling, which presented issues for families with limited internet access.
  • Magnification of disparities in health, causing the pandemic to impact BIPOC and disabled communities more so than other demographics worldwide.
  • Increase in hate crimes towards Asian-Americans, specifically Chinese-Americans related to COVID-19 related xenophobia.
  • Closure of businesses, offices, and restaurants resulted in increased unemployment and economic recession.
  • Vaccine hesitancy.
  • Cessation of non-essential medical procedures, delay of routine care, and conversion to telehealth as clinics and hospitals remained overwhelmed with COVID-19 patients.

The ethics of COVID-19 spans many more areas of medicine and society than represented in this paragraph — some of these principles will likely not be discovered until the end of the pandemic which, as of September 12, 2022, is still ongoing.

Values

A common framework used when analysing 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. 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.

The physician autonomy is a related though distinct concept.

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. 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.

Medical authoritarianism or authoritarian personality can contribute to medical harms.

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.

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 (2005) to advance the application of international human rights law in medical ethics. The Declaration provides special protection of human rights for incompetent persons.

Social justice or 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. 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. 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 refers to a patient's right to receive information relevant to a recommended treatment, in order to be able to make a well-considered, voluntary decision about their care. To give informed consent, a patient must be competent to make a decision regarding their treatment and be presented with relevant information regarding a treatment recommendation, including its nature and purpose, and the burdens, risks and potential benefits of all options and alternatives. After receiving and understanding this information, the patient can then make a fully informed decision to either consent or refuse treatment. In certain circumstances, there can be an exception to the need for informed consent, including, but not limited to, in cases of a medical emergency or patient incompetency. The ethical concept of informed consent also applies in a clinical research setting; all human participants in research must voluntarily decide to participate in the study after being fully informed of all relevant aspects of the research trial necessary to decide whether to participate or not. Informed consent is both an ethical and legal duty; if proper consent is not received prior to a procedure, treatment, or participation in research, providers can be held liable for battery and/or other torts. In the United States, informed consent is governed by both federal and state law, and the specific requirements for obtaining informed consent vary state to state.

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."

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. [40] 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). [41] Looking forward, strong governance and accountability mechanisms will need to be considered with respect to digital health ecosystems, including potential metaverse healthcare platforms, to ensure the highest ethical standards are upheld relating to medical confidentiality and patient data.

Control, resolution and enforcement

In the UK, medical ethics forms part of the training of physicians and surgeons and disregard for ethical principles can result in doctors barred from medical practice after a decision by the Medical Practitioners Tribunal Service.

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.