The application of moral philosophy to the field of medicine is no new concept; the original Hippocratic Oath dates back to the fifth century BCE. [4] However, the term “medical ethics” was defined in the early nineteenth century by Thomas Percival, who wrote an early code of ethics, describing the professional duties and ideal behavior of a physician. When the American Medical Association (AMA) held its first meeting in 1847, it based its own code of ethics heavily upon Percival’s. [5] The AMA’s code of ethics has evolved greatly since then; as technology and medical knowledge has advanced, physicians find themselves in increasingly morally gray situations. Currently, four fundamental principles of ethics, put forward by Tom Beauchamp and James Childress in their book Principles of Biomedical Ethics, are extremely influential in modern medical ethics: autonomy, beneficence, non-maleficence, and justice.
Autonomy refers to the right of the patient or individual to make their own choices. It is the basis for informed consent.
Non-maleficence is the principle of always acting with the interest of others in mind; in other words, to never knowingly directly or indirectly cause harm to the patient. It is the “above all, do no harm” principle.
Beneficence takes non-maleficence a step further and speaks to the duty to be an active benefit to the patient. It is occasionally argued that non-maleficence is a constant requirement, while beneficence can only be practiced to the best of one’s ability.
The principle of justice deals with fairness and equity. It implies fair distribution of medical goods and services. [5]
These principles might seem obvious and intuitive, and they are. But, they are also non-hierarchical; no principle takes precedence over any other. As a result, upholding all of them all of the time, particularly in a practical, applied sense, is a tricky balancing act. In fact, despite their influence, the principles of Beauchamp and Childress have also been criticized for their abstractness and nonspecificity[4]. Say the child of an anonymous sperm donor is diagnosed with a tumor that could have been fatal if it hadn’t been discovered early. This child wishes to contact her birth father in order to obtain his medical history, so she can know if she is at further risk for other cancers or inheritable diseases. No matter what the physician does - allow or disallow - they betray someone’s autonomy (right to have their choices respected). To make matters more complicated, would the physician betray the principle of beneficence by actively not taking a course of action that would benefit their patient? In other words, the best course of action isn’t always clear, and these principles can conflict with each other. When they do, it sometimes can be helpful to consider ethical dilemmas from other, more practical ethical philosophies: utilitarianism and deontology (often referred to as Kantian deontology).
Utilitarianism is a form of consequentialism - which argues that the moral value of an action is entirely determined by its consequences. Specifically, utilitarianism argues that the morally correct action is the one that maximizes the amount of good (utility). It justifies harm to individuals if the end result benefits a greater number of people. [3] In medical practice, this corresponds to the actions that best serve society and the collective good. Furthermore, a utilitarian idea of good is entirely decentered. No one person’s positive actions are worth more than another’s; positive consequences affecting one person are not worth more than those same consequences affecting another. [2] The fact that utilitarianism revolves around this single principle of net utility, determined entirely by the consequences of one’s actions, allows it to be a more simple and intuitive way of judging a medical decision than Beauchamp and Childress’s ethical theory. Without a need to arbitrate between different principles and with a quantitative way of calculating net utility, this ethical theory is clearer and more practical.
However, the same quality that makes utilitarianism so effective also creates its major downfall: it does not take seriously the distinction between people. What matters under utilitarianism is the net utility, not its distribution. Therefore, it justifies policies where a small group of people suffers in order to benefit a larger group of people. A strictly utilitarian view of ethics would support policies that take resources away from socioeconomic minorities in favor of the majority. This flaw most often comes up when evaluating the distribution of medical resources.
On the other hand, with deontology, the moral value of an action depends on the nature of the action itself. [1] In morally unambiguous medical situations, a physician can ideally default to a deontological approach, putting focus on proactively helping each individual patient to the best of their ability. However, physicians are often driven to a utilitarian approach when either it is unclear what action would best benefit the individual, or when their loyalties to different individuals come into competition, as in the sperm donor example. On the other hand, while utilitarianism would justify the forced quarantine of sick individuals to benefit the greater good, a deontological approach would put the good of the individual first, and not morally justify a forced quarantine.
As ethics turns more towards empiricism and we see a generalized shift towards utilitarian ideologies in healthcare [4], I believe combining Beauchamp and Childress’ principles with this more practical framework can address some of the criticism directed towards the former by perhaps not making decisions easier, but at least simpler. Take the example involving the patient with the sperm donor father. The four principles provide little in the way of guidance and perhaps complicate the problem. The physician might keep the spirit of the principles but view the problem through a utilitarian framework. They would consider the severity of the patient’s cancer, perhaps the known genetic history of her mother, and weigh the positive consequences for the patient from knowing her full genetic history against the potential negative consequences for the father from having his identity revealed to his daughter. No longer is the physician torn between loyalties and vaguely defined duties; it becomes a simple math problem.
Most importantly, as ethical dilemmas in the field of medicine become more and more nuanced, it is imperative to consider them through multiple philosophical frameworks and with a spirit of empathy, neither losing sight of the common good, nor of the individuals who make it up.
References
Bentham, J. (2018). An Introduction to the Principles of Morals and Legislation. CreateSpace Independent Publishing Platform.
The History of Utilitarianism (Stanford Encyclopedia of Philosophy). (2014, September 22). Stanford Encyclopedia of Philosophy. https://plato.stanford.edu/entries/utilitarianism-history/#JerBen
Mandal, J., Ponnambath, D., & Parija, S. (2016). Utilitarian and deontological ethics in medicine. Tropical Parasitology, 6(1), 5. https://doi.org/10.4103/2229-5070.175024
McCormick, T. R. (n.d.). Principles of Bioethics. UW Department of Bioethics & Humanities. Retrieved October 25, 2021, from https://depts.washington.edu/bhdept/ethics-medicine/bioethics-topics/articles/principles-bioethics
Riddick F. A., Jr (2003). The code of medical ethics of the american medical association. The Ochsner journal, 5(2), 6–10.