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- World Medical Association Medical Ethics Manual (2005 , World Medical Assoc)
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Medical Ethics Manual – Principal Features of Medical Ethics
WORLD MEDICAL ASSOCIATION
World Medical Association
Medical Ethics Manual
Medical student holding a newborn © Roger Ball/CORBIS
Medical Ethics
Manual
Medical Ethics Manual – Principal Features of Medical Ethics
· Confidentiality · Beginning-of-life issues · End-of-life issues · Back to the case study
Chapter Three - Physicians and Society ................................
· Objectives · Case study · What’s special about the physician-society relationship? · Dual loyalty · Resource allocation · Public health · Global health · Back to the case study
Chapter Four - Physicians and Colleagues .........................
· Objectives · Case study · Challenges to medical authority · Relationships with physician colleagues, teachers and students · Reporting unsafe or unethical practices · Relationships with other health professionals · Cooperation · Conflict resolution · Back to the case study
Chapter Five - Medical Research ................................................
· Objectives · Case study · Importance of medical research · Research in medical practice · Ethical requirements
Medical Ethics Manual – Table of Contents
- Ethics review committee approval
- Scientific merit
- Social value
- Risks and benefits
- Informed consent
- Confidentiality
- Conflict of roles
- Honest reporting of results
- Whistle blowing
- Unresolved issues · Back to the case study
Chapter Six - Conclusion ................................................................ · Responsibilities and privileges of physicians · Responsibilities to oneself · The future of medical ethics
Appendix A – Glossary (includes words in italic print in the text) .................................... Appendix B – Medical Ethics Resources on the Internet .......... Appendix C – World Medical Association: Resolution on the Inclusion of Medical Ethics and Human Rights in the Curriculum of Medical Schools World-Wide, and World Federation for Medical Education: Global Standards for Quality Improvement – Basic Medical Education .................................................................. Appendix D – Strengthening Ethics Teaching in Medical Schools .................................................................................. Appendix E – Additional Case Studies ............................................
Medical Ethics Manual – Principal Features of Medical Ethics
ACKNOWLEDGMENTS
The WMA Ethics Unit is profoundly grateful to the following individuals for providing extensive and thoughtful comments on earlier drafts of this Manual:
Prof. Solly Benatar, University of Cape Town, South Africa
Prof. Kenneth Boyd, University of Edinburgh, Scotland
Dr. Annette J. Braunack-Mayer, University of Adelaide, Australia
Dr. Robert Carlson, University of Edinburgh, Scotland
Mr. Sev Fluss, WMA and CIOMS, Geneva, Switzerland
Prof. Eugenijus Gefenas, University of Vilnius, Lithuania
Dr. Delon Human, WMA, Ferney-Voltaire, France
Dr. Girish Bobby Kapur, George Washington University, Washington, DC, USA
Prof. Nuala Kenny, Dalhousie University, Halifax, Canada
Prof. Cheryl Cox Macpherson, St. George’s University, Grenada
Ms. Mareike Moeller, Medizinische Hochschule Hannover, Germany
Prof. Ferenc Oberfrank, Hungarian Academy of Sciences, Budapest, Hungary
Mr. Atif Rahman, Khyber Medical College, Peshawar, Pakistan
Mr. Mohamed Swailem, Banha Faculty of Medicine, Banha, Egypt, and his ten fellow students who identified vocabulary that was not familiar to individuals whose first language is other than English.
The WMA Ethics Unit is supported in part by an unrestricted educational grant from Johnson & Johnson.
FOREWORD Dr. Delon Human Secretary General World Medical Association
It is incredible to think that although the founders of medical ethics, such as Hippocrates, published their works more than 2000 years ago, the medical profession, up until now, has not had a basic, universally used, curriculum for the teaching of medical ethics. This first WMA Ethics Manual aims to fill that void. What a privilege it is to introduce it to you! The Manual’s origin dates back to the 51st World Medical Assembly in 1999. Physicians gathered there, representing medical associations from around the world, decided, “to strongly recommend to Medical Schools worldwide that the teaching of Medical Ethics and Human Rights be included as an obligatory course in their curricula.” In line with that decision, a process was started to develop a basic teaching aid on medical ethics for all medical students and physicians that would be based on WMA policies, but not be a policy document itself. This Manual, therefore, is the result of a comprehensive global developmental and consultative process, guided and coordinated by the WMA Ethics Unit. Modern healthcare has given rise to extremely complex and multifaceted ethical dilemmas. All too often physicians are unprepared to manage these competently. This publication is specifically structured to reinforce and strengthen the ethical mindset and practice of physicians and provide tools to find ethical solutions to these dilemmas. It is not a list of “rights and wrongs” but an attempt to sensitise the conscience of the physician, which is the basis for all sound and ethical decision-making. To this end, you will find several case studies in the book, which are intended to
Medical Ethics Manual – Foreword
Medical Ethics Manual – Principal Features of Medical Ethics
the patients that obviously bother the assisting nurses. As a more junior staff member, Dr. C is reluctant to criticize the surgeon personally or to report him to higher authorities. However, he feels that he must do something to improve the situation.
- Dr. R, a general practitioner in a small rural town, is approached by a contract research organization (C.R.) to participate in a clinical trial of a new non-steroidal anti-inflammatory drug (NSAID) for osteoarthritis. She is offered a sum of money for each patient that she enrols in the trial. The C.R. representative assures her that the trial has received all the necessary approvals, including one from an ethics review committee. Dr. R has never participated in a trial before and is pleased to have this opportunity, especially with the extra money. She accepts without inquiring further about the scientific or ethical aspects of the trial.
Each of these case studies invites ethical reflection. They raise questions about physician behaviour and decision-making – not scientific or technical questions such as how to treat diabetes or how to perform a double bypass, but questions about values, rights and responsibilities. Physicians face these kinds of questions just as often as scientific and technical ones.
In medical practice, no matter what the specialty or the setting, some questions are much easier to answer than others. Setting a simple fracture and suturing a simple laceration pose few challenges to physicians who are accustomed to performing these procedures. At the other end of the spectrum, there can be great uncertainty or disagreement about how to treat some diseases, even common ones such as tuberculosis and hypertension. Likewise, ethical questions in medicine are not all equally challenging. Some are relatively easy to answer, mainly because there is a well-developed consensus on the right way to act in the situation (for example, the
physician should always ask for a patient’s consent to serve as a research subject). Others are much more difficult, especially those for which no consensus has developed or where all the alternatives have drawbacks (for example, rationing of scarce healthcare resources).
So, what exactly is ethics and how does it help physicians deal with such questions? Put simply, ethics is the study of morality – careful and systematic reflection on and analysis of moral decisions and behaviour, whether past, present or future. Morality is the value dimension of human decision-making and behaviour. The language of morality includes nouns such as ‘rights’, ‘responsibilities’ and ‘virtues’ and adjectives such as ‘good’ and ‘bad’ (or ‘evil’), ‘right’ and ‘wrong’, ‘just’ and ‘unjust’. According to these definitions, ethics is primarily a matter of knowing whereas morality is a matter of doing. Their close relationship consists in the concern of ethics to provide rational criteria for people to decide or behave in some ways rather than others. Since ethics deals with all aspects of human behaviour and decision-making, it is a very large and complex field of study with many branches or subdivisions. The focus of this Manual is medical ethics, the branch of ethics that deals with moral issues in medical practice. Medical ethics is closely related, but not identical to, bioethics (biomedical ethics). Whereas medical ethics focuses primarily on issues arising out of the practice of medicine, bioethics is a very broad subject that is concerned with the moral issues raised by developments in the biological sciences more generally. Bioethics also differs from medical ethics insofar as it does not require the acceptance of certain traditional values
Medical Ethics Manual – Introduction
“.. is the study of morality – careful and systematic reflection on and analysis of moral decisions and behaviour”
Medical Ethics Manual – Principal Features of Medical Ethics
that, as we will see in Chapter Two, are fundamental to medical ethics.
As an academic discipline, medical ethics has developed its own specialized vocabulary, including many terms that have been borrowed from philosophy. This Manual does not presuppose any familiarity with philosophy in its readers, and therefore definitions of key terms are provided either where they occur in the text or in the glossary at the end of the Manual.
WHY STUDY MEDICAL ETHICS?
“As long as the physician is a knowledgeable and skilful clinician, ethics doesn’t matter.”
“Ethics is learned in the family, not in medical school.”
“Medical ethics is learned by observing how senior physicians act, not from books or lectures.”
“Ethics is important, but our curriculum is already too crowded and there is no room for ethics teaching.”
These are some of the common reasons given for not assigning ethics a major role in the medical school curriculum. Each of them is partially, but only partially, valid. Increasingly throughout the world medical schools are realising that they need to provide their students with adequate time and resources for learning ethics. They have received strong encouragement to move in this direction from organizations such as the World Medical Association and the World Federation for Medical Education (cf. Appendix C).
The importance of ethics in medical education will become apparent throughout this Manual. To summarize, ethics is and always has been an essential component of medical practice. Ethical principles such as respect for persons, informed consent and confidentiality are basic to the physician-patient relationship. However, the
application of these principles in specific situations is often problematic, since physicians, patients, their family members and other healthcare personnel may disagree about what is the right way to act in a situation. The study of ethics prepares medical students to recognize difficult situations and to deal with them in a rational and principled manner. Ethics is also important in physicians’ interactions with society and their colleagues and for the conduct of medical research.
MEDICAL ETHICS, MEDICAL
PROFESSIONALISM, HUMAN RIGHTS AND LAW
As will be seen in Chapter One, ethics has been an integral part of medicine at least since the time of Hippocrates, the fifth century B.C. (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 (cf. Chapter Three for further explanation). The close relationship of ethics and professionalism will be evident throughout this Manual. 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
Medical Ethics Manual – Introduction
“ The study of ethics prepares medical students to recognize difficult situations and to deal with them in a rational and principled manner.”
Medical Ethics Manual – Principal Features of Medical Ethics
CHAPTER ONE –
PRINCIPAL FEATURES OF MEDICAL ETHICS
OBJECTIVES After working through this chapter you should be able to: · explain why ethics is important to medicine · identify the major sources of medical ethics · recognize different approaches to ethical decision-making, A Day in the Life of a French General Practitioner including your own. © Gilles Fonlupt/Corbis
Medical Ethics Manual – Principal Features of Medical Ethics
WHATʼS SPECIAL ABOUT MEDICINE?
Throughout almost all of recorded history and in virtually every part of the world, being a physician has meant something special. People come to physicians for help with their most pressing needs – relief from pain and suffering and restoration of health and well-being. They allow physicians to see, touch and manipulate every part of their bodies, even the most intimate. They do this because they trust their physicians to act in their best interests.
The status of physicians differs from one country to another and even within countries. In general, though, it seems to be deteriorating. Many physicians feel that they are no longer as respected as they once were. In some countries, control of healthcare has moved steadily away from physicians to professional managers and bureaucrats, some of whom tend to see physicians as obstacles to rather than partners in healthcare reforms. Patients who used to accept physicians’ orders unquestioningly sometimes ask physicians to defend their recommendations if these are different from advice obtained from other health practitioners or the Internet. Some procedures that formerly only physicians were capable of performing are now done by medical technicians, nurses or paramedics.
Despite these changes impinging on the status of physicians, medicine continues to be a profession that is highly valued by the sick people who need its services. It also continues to attract large numbers of the most gifted, hard-working and dedicated students. In order to meet
the expectations of both patients and students, it is important that physicians know and exemplify the core values of medicine, especially compassion, competence and autonomy. These values, along with respect for fundamental human rights, serve as the foundation of medical ethics.
WHATʼS SPECIAL ABOUT MEDICAL ETHICS?
Compassion, competence and autonomy are not exclusive to medicine. However, physicians are expected to exemplify them to a higher degree than other people, including members of many other professions. Compassion, defined as understanding and concern for another person’s distress, is essential for the practice of medicine. In order to deal with the patient’s problems, the physician must identify the symptoms that the patient is experiencing and their underlying causes and must want to help the patient achieve relief. Patients respond better to treatment if they perceive that the physician appreciates their concerns and is treating them rather than just their illness. A very high degree of competence is both expected and required of physicians. A lack of competence can result in death or serious morbidity for patients. Physicians undergo a long training period to ensure competence, but considering the rapid advance of medical knowledge, it is a continual challenge for them to maintain their competence. Moreover, it is not just their scientific knowledge and technical skills that they have to maintain but their ethical knowledge, skills and attitudes as well, since new ethical issues arise with changes in medical practice and its social and political environment. Autonomy, or self-determination, is the core value of medicine that has changed the most over the years. Individual physicians have
“Many physicians feel that they are no longer as respected as they once were.”
“.. meet the expectations of both patients and students, it is important that physicians know and exemplify the core values of medicine”
Medical Ethics Manual – Principal Features of Medical Ethics
culture and religion often play a dominant role in determining ethical behaviour.
The answer to the question, “who decides what is ethical for people in general?” therefore varies from one society to another and even within the same society. In liberal societies, individuals have a great deal of freedom to decide for themselves what is ethical, although they will likely be influenced by their families, friends, religion, the media and other external sources. In more traditional societies, family and clan elders, religious authorities and political leaders usually have a greater role than individuals in determining what is ethical.
Despite these differences, it seems that most human beings can agree on some fundamental ethical principles, namely, the basic human rights proclaimed in the United Nations Universal Declaration of Human Rights and other widely accepted and officially endorsed documents. The human rights that are especially important for medical ethics include the right to life, to freedom from discrimination, torture and cruel, inhuman or degrading treatment, to freedom of opinion and expression, to equal access to public services in one’s country, and to medical care.
For physicians, the question, “who decides what is ethical?” has until recently had a somewhat different answer than for people in general. Over the centuries the medical profession has developed its own standards of behaviour for its members, which are expressed in codes of ethics and related policy documents. At the global level, the WMA has set forth a broad range of ethical statements that specify the behaviour required of physicians no matter where they live and practise. In many, if not most, countries medical associations have been responsible for developing and enforcing the applicable ethical standards. Depending on the country’s approach to medical law, these standards may have legal status.
The medical profession’s privilege of being able to determine its own ethical standards has never been absolute, however. For example:
- Physicians have always been subject to the general laws of the land and have sometimes been punished for acting contrary to these laws.
- Some medical organizations are strongly influenced by religious teachings, which impose additional obligations on their members besides those applicable to all physicians.
- In many countries the organizations that set the standards for physician behaviour and monitor their compliance now have a significant non-physician membership. The ethical directives of medical associations are general in nature; they cannot deal with every situation that physicians might face in their medical practice. In most situations, physicians have to decide for themselves what is the right way to act, but in making decisions, it is helpful to know what other physicians would do in similar situations. Medical codes of ethics and policy statements reflect a general consensus about the way physicians should act and they should be followed unless there are good reasons for acting otherwise.
DOES MEDICAL ETHICS CHANGE?
There can be little doubt that some aspects of medical ethics have changed over the years. Until recently physicians had the right and the duty to decide how patients should be treated and there was no obligation to obtain the patient’s informed consent. In contrast, the 1995 version of the WMA Declaration on the Rights of the Patient
“.. making decisions, it is helpful to know what other physicians would do in similar situations.”
Medical Ethics Manual – Principal Features of Medical Ethics
begins with this statement: “The relationship between physicians, their patients and broader society has undergone significant changes in recent times. While a physician should always act according to his/ her conscience, and always in the best interests of the patient, equal effort must be made to guarantee patient autonomy and justice.” Many individuals now consider that they are their own primary health providers and that the role of physicians is to act as their consultants or instructors. Although this emphasis on self-care is far from universal, it does seem to be spreading and is symptomatic of a more general evolution in the patient-physician relationship that gives rise to different ethical obligations for physicians than previously.
Until recently, physicians generally considered themselves accountable only to themselves, to their colleagues in the medical profession and, for religious believers, to God. Nowadays, they have additional accountabilities – to their patients, to third parties such as hospitals and managed healthcare organizations, to medical licensing and regulatory authorities, and often to courts of law. These different accountabilities can conflict with one another, as will be evident in the discussion of dual loyalty in Chapter Three.
Medical ethics has changed in other ways. Participation in abortion was forbidden in medical codes of ethics until recently but now is tolerated under certain conditions by the medical profession in many countries. Whereas in traditional medical ethics the sole responsibility of physicians was to their individual patients, nowadays it is generally agreed that physicians should also consider the needs of society, for example, in allocating scarce healthcare resources (cf. Chapter Three).
Advances in medical science and technology raise new ethical issues that cannot be answered by traditional medical ethics. Assisted reproduction, genetics, health informatics and life-extending and enhancing technologies, all of which require the participation of physicians, have great potential for benefiting patients but also potential for harm depending on how they are put into practice. To help physicians decide whether and under what conditions they should participate in these activities, medical associations need to use different analytic methods than simply relying on existing codes of ethics. Despite these obvious changes in medical ethics, there is widespread agreement among physicians that the fundamental values and ethical principles of medicine do not, or at least should not, change. Since it is inevitable that human beings will always be subject to illness, they will continue to have need of compassionate, competent and autonomous physicians to care for them.
DOES MEDICAL ETHICS 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 that do not
“.. accountabilities can conflict with one another”
Medical Ethics Manual – Principal Features of Medical Ethics
example, the most recent revision of the Declaration of Helsinki was begun early in 1997 and completed only in October 2000. Even then, outstanding issues remained and these continued to be studied by the Medical Ethics Committee and successive workgroups.
A good process is essential to, but does not guarantee, a good outcome. In deciding what is ethical, the WMA draws upon a long tradition of medical ethics as reflected in its previous ethical statements. It also takes note of other positions on the topic under consideration, both of national and international organizations and of individuals with skill in ethics. On some issues, such as informed consent, the WMA finds itself in agreement with the majority view. On others, such as the confidentiality of personal medical information, the position of physicians may have to be promoted forcefully against those of governments, health system administrators and/or commercial enterprises. A defining feature of the WMA’s approach to ethics is the priority that it assigns to the individual patient or research subject. In reciting the Declaration of Geneva, the physician promises, “The health of my patient will be my first consideration.” And the Declaration of Helsinki states, “In medical research on human subjects, considerations related to the well-being of the human subject should take precedence over the interests of science and society.”
HOW DO INDIVIDUALS DECIDE WHAT IS ETHICAL?
For individual physicians and medical students, medical ethics does not consist simply in following the recommendations of the WMA
or other medical organizations. These recommendations are usually general in nature and individuals need to determine whether or not they apply to the situation at hand. Moreover, many ethical issues arise in medical practice for which there is no guidance from medical associations. Individuals are ultimately responsible for making their own ethical decisions and for implementing them.
There are different ways of approaching ethical issues such as the ones in the cases at the beginning of this Manual. These can be divided roughly into two categories: non-rational and rational. It is important to note that non-rational does not mean irrational but simply that it is to be distinguished from the systematic, reflective use of reason in decision-making.
Non-rational approaches:
- Obedience is a common way of making ethical decisions, especially by children and those who work within authoritarian structures (e., the military, police, some religious organizations, many businesses). Morality consists in following the rules or instructions of those in authority, whether or not you agree with them.
- Imitation is similar to obedience in that it subordinates one’s judgement about right and wrong to that of another person, in this case, a role model. Morality consists in following the example of the role model. This has been perhaps the most common way of learning medical ethics by aspiring physicians, with the role models being the senior consultants and the mode of moral learning being observation and assimilation of the values portrayed.
“On some issues, ... the position of physicians may have to be promoted forcefully against those of governments, health system administrators and/or commercial enterprises.”
“Individuals are ultimately responsible for making their own ethical decisions and for implementing them.”
Medical Ethics Manual – Principal Features of Medical Ethics
Feeling or desire is a subjective approach to moral decision- making and behaviour. What is right is what feels right or satisfies one’s desire; what is wrong is what feels wrong or frustrates one’s desire. The measure of morality is to be found within each individual and, of course, can vary greatly from one individual to another, and even within the same individual over time.
Intuition is an immediate perception of the right way to act in a situation. It is similar to desire in that it is entirely subjective; however, it differs because of its location in the mind rather than the will. To that extent it comes closer to the rational forms of ethical decision-making than do obedience, imitation, feeling and desire. However, it is neither systematic nor reflexive but directs moral decisions through a simple flash of insight. Like feeling and desire, it can vary greatly from one individual to another, and even within the same individual over time.
Habit is a very efficient method of moral decision-making since there is no need to repeat a systematic decision-making process each time a moral issue arises similar to one that has been dealt with previously. However, there are bad habits (e., lying) as well as good ones (e., truth-telling); moreover, situations that appear similar may require significantly different decisions. As useful as habit is, therefore, one cannot place all one’s confidence in it.
Rational approaches:
As the study of morality, ethics recognises the prevalence of these non-rational approaches to decision-making and behaviour. However, it is primarily concerned with rational approaches. Four such approaches are deontology, consequentialism, principlism and virtue ethics:
Deontology involves a search for well-founded rules that can serve as the basis for making moral decisions. An example of such a rule is, “Treat all people as equals.” Its foundation may be religious (for example, the belief that all God’s human creatures are equal) or non-religious (for example, human beings share almost all of the same genes). Once the rules are established, they have to be applied in specific situations, and here there is often room for disagreement about what the rules require (for example, whether the rule against killing another human being would prohibit abortion or capital punishment).
Consequentialism bases ethical decision-making on an analysis of the likely consequences or outcomes of different choices and actions. The right action is the one that produces the best outcomes. Of course there can be disagreement about what counts as a good outcome. One of the best-known forms of consequentialism, namely utilitarianism, uses ‘utility’ as its measure and defines this as ‘the greatest good for the greatest number’. Other outcome measures used in healthcare decision-making include cost-effectiveness and quality of life as measured in QALYs (quality-adjusted life-years) or DALYs (disability-adjusted life-years). Supporters of consequentialism generally do not have much use for principles; they are too difficult to identify, prioritise and apply, and in any case they do not take into account what in their view really matters in moral decision-making, i., the outcomes. However, this setting aside of principles leaves consequentialism open to the charge that it accepts that ‘the end justifies the means’, for example, that individual human rights can be sacrificed to attain a social goal.
Principlism, as its name implies, uses ethical principles as the basis for making moral decisions. It applies these principles to particular cases or situations in order to determine what
Medical Ethics Manual – Principal Features of Medical Ethics
very valuable today. The WMA and other mCONCLUSION This chapter sets the stage for what follows. When dealing with specific issues in medical ethics, it is good to keep in mind that physicians have faced many of the same issues throughout history and that their accumulated experience and wisdom can be very valuable today. The WMA and other medical organizations carry on this tradition and provide much helpful ethical guidance to physicians. However, despite a large measure of consensus among physicians on ethical issues, individuals can and do disagree on how to deal with specific cases. Moreover, the views of physicians can be quite different from those of patients and of other healthcare providers. As a first step in resolving ethical conflicts, it is important for physicians to understand different approaches to ethical decision-making, including their own and those of the people with whom they are interacting. This will help them determine for themselves the best way to act and to explain their decisions to others.
Medical Ethics Manual – Principal Features of Medical Ethics
Medical Ethics Manual – Physicians and Patients
CHAPTER TWO –
PHYSICIANS AND PATIENTS
OBJECTIVES After working through this chapter you should be able to: · explain why all patients are deserving of respect and equal treatment; · identify the essential elements of informed consent; · explain how medical decisions should be made for patients who are incapable of making their own decisions; · explain the justification for patient confidentiality and recognise legitimate exceptions to confidentiality; · recognize the principal ethical issues that occur at the beginning and end of life; · summarize the arguments for and against the practice of euthanasia/assisted suicide and the difference between these actions and palliative care or forgoing treatment. Compassionate doctor © Jose Luis Pelaez, Inc./CORBIS
- World Medical Association Medical Ethics Manual (2005 , World Medical Assoc)
University: Jinan University
