A Conceptual Framework for Ethics
by Kevin O'Rourke, OP, JCD, STM
from Roger Boze, ed., Current Practice of Medicine, vol. I, Churchill & Livingstone, N.Y., 1996.
What is ethics? What is bioethics? How do we solve bioethical dilemmas? These are the main topics that will be studied in this chapter. The thoughts presented in this section are drawn from the historical study of ethics and 15 years' experience teaching and consulting in clinical medicine as an ethicist in a pluralistic medical community. Those familiar with the contemporary presentations of medical ethics may be concerned that this presentation says little about the three principles often presented as normative for medical ethics: that is, the principles of autonomy, beneficence, and justice. In our opinion, these principles have meaning only if based upon the following considerations.
Defining Good and Bad Actions
Ethics is an effort to determine which human actions are good and which human actions are bad. In order for an action to have ethical meaning, it must be a free action; that is, it must be subject to human control. Being subject to the laws of gravity is not a free action and therefore does not have ethical import. But whether or not you pay debts or fulfill your responsibilities toward parents, spouse, or children are actions that are subject to your free choice. Hence, these actions have ethical meaning.
In order to say that something is good for a person (beneficial) or bad for a person (harmful), there must be some agreement in regard to human fulfillment or well-being. In other words, one must have some notion of the purpose of life before one can say that actions are good or bad. If I believe that my well-being or my purpose of human life consists in amassing as much wealth as possible, any action that would help me amass wealth would be a good action. Hence, robbing banks and swindling widows and orphans would be good actions because they would help me achieve well being. But if I believe that amassing wealth is subservient to other goals, such as respecting the private property rights of other people, I have a different context for deciding which human actions are good and which are bad.
Clearly, determining the meaning of human fulfillment or the purpose of life will have a very important impact upon the determination of good and bad human actions. Striving for an accurate definition of this concept has occupied philosophers and theologians throughout the ages. At least subconsciously or implicitly, all of us have goals or purposes in life. When we ask ourselves: "What makes life worthwhile?" "What do I want to do in life?" "Do I went to spend money on a new car or invest the money to pay for my children's education?" We are asking questions that are concerned with human fulfillment or the purpose of life?
The Basic Human Needs
People describe human fulfillment or the purpose of life in different ways. In the Judeo-Christian tradition, human fulfillment is usually described as loving God, loving oneself and loving one's neighbor as oneself. The precise description of "loving actions" is the work of Jewish and Christian theology. A more pluralistic or philosophical way of describing human well-being is to say that it consists in fulfilling human needs in an integrated manner. Upon examination of the human person, we find there are physiological, psychological, social, and creative needs. -- While the word spiritual is often used to describe this fourth set of needs, I prefer to use the word creative because the word spiritual is often confined to religious concerns. The creative needs are the need to know, to love, to plan for the future, to learn from the past, to relate to others, etc. -- The functions of the human personality seek to fulfill these needs. Human needs and the functions that fulfill them are interrelated. For example, occasionally a young student will study so intently that his health suffers. The pursuit of creative needs hinders fulfillment of physiological needs; the creative function is not integrated with the physiological function.
Eating, drinking, enjoying friendships, studying, fulfill human needs and thus are good actions provided they are performed in a manner that is considerate of other needs. However, if a person does not fulfill a personal need in an integrated or balanced manner, for example, if one drinks so much that he is unable to work, then he performs a bad action. A rapist may fulfill a need for physical and psychological pleasure by obtaining pleasure through sexual activity, but he is abusing his social and creative needs. Sexual activity should he entered into freely and should be prompted by mutual love. By violently forcing someone else to perform a sexual action with him, the rapist violates the responsibility to integrate social and creative needs with pleasure needs. Thus rape is a bad action; harmful to the rapist as well as the victim.
Rights, Values, Laws
The word "right" is often used to indicate a person's freedom to perform actions that fulfill human needs, and a correlative responsibility on the part of other persons not to hinder or prevent a person from performing the good action in question. Rights are called natural if they arise from nature and acquired if they arise from the development of human culture. Thus the right to food, friends, and knowledge are natural rights. The right to a job, education, or health care are acquired rights. Rights are called inalienable if they seem to he necessary for a person's purpose in life. Rights are called equity rights if they contribute to achieving the purpose of life but are not absolutely necessary in order to achieve that purpose. Equity rights are often balanced against one another, while inalienable rights are preemptive of equity rights.
As culture progresses, some equity rights become inalienable rights. In the United States, seeking a basic education was considered an equity right 200 years ago. Today, we would consider education to be integrally connected with a fulfilled life and hence would describe it as an inalienable right. Today there is dispute in our country over whether the right to health care is a natural right or an equity right.
The founders of our country were enumerating human needs necessary for human fulfillment when they stated inalienable rights in the Constitution. When they spoke about "life, liberty, the pursuit of happiness, freedom of religion and speech" they sought to describe some of the fundamental needs to which people have inalienable rights. Most of the inalienable rights in the Constitution are acquired rights, the result of cultural development. More then 30 basic rights are listed in the Declaration of Human Rights issued by the United Nations.
If an act fulfills a human need in an integrated manner, it is called good; An act that does not fulfill human need in a balanced manner is celled bad. A good act is also called a value; an act that is bad is called a disvalue. Thus, a value is not some vague source of human behavior, as contemporary speakers often indicate, (e.g.,"We all have different values that have to be respected.") Rather, a value is a definite pronouncement that some action fulfills integrated human needs.
When considering which actions are good and which actions are bad, we realize that many actions are good or bad for all people. In other words, people have needs in common. Fulfilling these common needs is intrinsically related to human well-being. If one does not realize that there are common needs, ethical reasoning results in moral relativism. That is, unless we acknowledge that certain actions help everyone achieve the purpose of life, and other actions make it difficult or impossible for everyone to achieve the purpose of life, the result of ethical reflection becomes totally subjective.
Our laws against violence and murder and our laws concerning taxes are based upon the concept of common needs. In general, needs that are common to everyone are such things as the need to prolong life, to pursue knowledge and health, to form communities of friendship and family, to respect the property rights of others, and to work together for the common good. If human beings do not have a common and shared notion of which actions are beneficial and which actions are harmful, they would never be able to fulfill their social needs or to form communities. Peaceful life in society is impossible without consensus in regard to good end bad actions and the rights associated with these actions.
In order to educate people concerning good and bad actions and coerce people to respect the rights of others, laws are promulgated and enforced. Laws cannot be formulated and enforced unless there is consensus in regard to basic human needs and the right to be free in pursuing these needs.
Of course, there will never be complete uniformity in regard to good and bad human actions, because we have individual needs as well as needs in common. Rules or laws will not be able to guide all ethical decisions, What may be a good act for you because of some particular need may not be a good act for me, because we do not have the same need. In sum, some needs and ethical determinations will be shared with others, and some needs and ethical determinations will be particular to individual people.
Valid Basis for Individual Ethical Desire
How do people make individual decisions about good and bad human actions? How do people decide that some action will or will not fulfill a basic or acquired need in an integrated manner? Some people depend on emotion -- e.g., "I know rape is wrong because I feel strongly against it." Some depend upon the law -- e.g., "Rape must be wrong because there is a law against it." Some look to the custom of society -- e.g., "Rape is wrong because our society has always considered it a crime." Some depend upon religious directions -- e.g., "Rape is wrong because it is against God's law."
All these approaches have something to contribute insofar as determining good and bad behavior is concerned. But in order to form ethical judgments that are valid in a pluralistic society, we must probe deeper and find a common basis for ethical decisions. Human reason is the power that offers a basis for shared or common decision making. Reason allows us to form objective evaluations about good and bad human actions. For example, reason tells us that rape is wrong because it perverts the nature of sexual activity and does not fulfill human needs in an integrated manner. Emotions, customs, and faith are important in forming ethical decisions but are fundamentally subjective and thus do not substantiate shared values. Even those teachings that are set forth by various Churches, and that depend upon faith for acceptance, are usually supported by human reason if the Church presenting such teaching seeks to participate actively in our pluralistic society. Law is also helpful in determining right end wrong but does not offer fundamental reasons to substantiate it. In order to probe and discern in the most fundamental way possible which actions do or do not fulfill human needs in an integrated manner, it is necessary to use reason.
Moreover, as we use reason to provide objective evidence concerning the ethical evaluation of human actions, we must avoid utilitarian or consequentialism. Thus, when we use human reason to probe whether or not a particular action fulfills a human need in a balanced way, we cannot look only to the ultimate effect of the action in question. Rather, we must consider the proximate effect of the action as well. Would it be accurate to describe a series of thefts as good actions simply because they have a beneficial ultimate purpose? For example, if my ultimate purpose is to obtain money for tuition so that I can go to college, can I describe a series of thefts that enable me to obtain money for tuition as good actions? In order to be ethically accurate, each human action must be evaluated insofar as its own specific ethical effect is concerned (does it foster or inhibit human fulfillment). Consequentialism may seem to simplify ethical reasoning (do whatever works out best for you in the long run), but it is unacceptable if one is concerned with true human fulfillment.
A contemporary example of evaluating human actions by means of human reason is the work of the President's Commission for the Study of Ethics in Medicine and Behavioral and Biomedical Research. This Commission completed its work in the early 1980s and provided a framework for ethical decision making that can be shared by the general public.
Ethics is not easy. Our experience demonstrates that discerning good and bad actions through human reason is a very difficult and error prone process. What are the dispositions for error? First, we observe that some actions that are good in one era may be considered bad in another era, and vice versa. At one time, smoking cigarettes was considered a good action because it enabled a person to fulfill a need for sense pleasure. Now, however, because of additional information, smoking is considered harmful, or a bad action, because it is detrimental to the need to protect one's physiological well-being.
Second, we realize that every human act has many circumstances, and circumstances affect our ethical evaluations in determining whether the act will be good or bad. The age and physical condition of a patient, for example, makes a difference when determining whether a particular medical or surgical procedure will be beneficial for the patient's physiological needs. Thus experience leads us to be very careful in defining good and bad human actions and leads us to realize that circumstances may often change an ethical evaluation.
Third, though we strive sincerely to make accurate ethical judgments, we are often wrong. Given the possibility of error of ethical reasoning, the probity of our ethical efforts depends more on following a careful reasoning process than on the ultimate evaluation of what will be a good or bad action in a particular situation.
What does this somewhat extended discussion of general ethics end shared values have to do with bioethics and physicians? Bioethics is simply a subsection of general ethics. Bioethics is concerned with evaluating human actions resulting from the application of biological knowledge to human needs. Because the medical profession involves the application of biological sciences to human needs, the term bioethics is used to delineate the ethical issues that arise in the practice of medicine. The terms medical ethics and health care ethics are also used to describe the effort to form judgments about good and bad actions involving the application of biological knowledge. Sometimes the term health care ethics includes social issues arising from the pursuit of health, such as equal access to health care and methods of financing health care, as well as the actions proper to the patient-physician relationships.
In keeping with the concepts discussed above concerning ethics in general, it is clear that in order to understand the ethical responsibilities of medicine, one must understand the purpose of medicine. What human needs does medicine seek to fulfill? The primary purpose of medicine is to help people pursue health. But the term health has two distinct meanings. Health is often limited to physiological and psychological well-being. This incomplete and limited sense of the term is assumed by many health care professionals to be the adequate and acceptable purpose of health care. But in the proper sense of the term, health has a fuller and more accurate meaning. In this sense, it includes social and creative well-being of the individual as well as physiological and psychological well-being.
This more accurate notion of health is the substance of the definition presented by the World Health Organization: "Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." In this broader notion of human health, the physiological and psychological well-being of the person may be viewed as a substructure for the social and the creative well-being of the person. To put it another way, the social and creative functions of the person have greater value, and are directive of the physiological and psychological functions. But the well-being of the social and creative functions depends intimately upon the well-being of the physiological and psychological functions. In other words, the physiological and psychological function contribute to more effective social and creative functions.
Even though the purpose of medical care is health in this wider sense of the term, nonetheless the physician is concerned primarily, but not exclusively, with the physiological and psychological functions of the person. Physicians ate trained to be experts in understanding the physiological and psychological functions. Hence, physicians make certain judgments and offer advice about these two aspects of human health. This usually is referred to as offering a diagnosis and prognosis. Patients are the experts in regard to their own social and creative well-being. The patient is responsible for assessing his or her social and creative needs in accord with objective evidence and the actions that fulfill those needs. The goods that people consider necessary to fulfill their social and creative needs are often referred to as a value system. Thus, the patient makes the ultimate decisions in regard to medical care, but these decisions should be based upon the objective information derived from the knowledge and the skill of the physician.
The physician has ethical responsibilities over and above the responsibility to follow the choices for treatment made by the patient. Physicians assume the responsibility of being experts at diagnosis and prognosis, and of communicating honestly and effectively their knowledge and recommendations concerning effective therapies to the patient. If a patient were to choose a therapy that the physician thought to be injurious or ineffective, or refuse a therapy that the physician considered to contribute toward physiological well-being, the physician should express his or her medical opinion. A simple example of this responsibility would be the request for laetrile treatments by a person with cancer. A competent physician would refuse to offer such treatment because it has been proven ineffective. More complicated cases occur when a person with a fatal pathology wishes to forgo effective medical treatment because he or she believes prolonging life would be a grave burden. The patient's value system may lend to refusal of effective treatment.
The Patient-Physician Relationship
Human health depends on many factors -- e.g, genetic inheritance, environmental surroundings, personal attitudes and behavior, and medical care. In this study, we are interested only in considering the ethical responsibilities Associated with medical care. In order to understand these responsibilities, we must probe more deeply the relationship that enables a health care professional to offer help to a person desirous of fulfilling the need for physiological well-being. In other words, in order to understand the essence of biomedical ethics, and describe its principal norms, we must understand the physician-patient relationship. This relationship enables the participants to strive for the goals of medicine. Without a mutually responsive physician-patient relationship, ethical medical care is not possible.
In the physician-patient relationship a physician promises to put his other knowledge and skill at the service of a patient in order to help the patient pursue the very basic need of physiological and psychological well-being. The motivation of the physician is altruistic in the sense that he or she would provide this help even if he or she were financially independent. But because the physician is not financially independent, the patient or society (patients as a group) assumes the responsibility of providing adequate sustenance for the physician in order to allow the physician to dedicate himself or herself to this important profession. In order to help the patient, the physician promises to be knowledgeable and skilled in physiological and psychological functions -- that is, to be able to offer an accurate diagnosis and prognosis.
The physician must also respect the patient's need and right to make decisions that affect social or creative needs. Moreover, physicians must strive to foster a bond of trust with the patient. The good that both physician and patient are pursuing, namely, the physiological and psychological health of the patient, is dependent upon a trusting relationship. The patient's guest for health will be hindered if he or she does not believe that the physician is acting totally on the patient's behalf when diagnosing and prescribing regimen, medicine, or surgery to restore or preserve physiological or psychological function.
Ethical Norms for Physicians
In an effort to express our common understanding of what is good and had, and to save the work of evaluating anew every free action, people seek to formulate general norms to indicate good and bad actions, hence, there are norms such as do not murder, do not rape, do not steal, be generous to the poor, take care of your health, and countless other positive or negative norms that bespeak a previous ethical evaluation of such actions and a common agreement in regard to their value or disvalue.
From the notion that human health is total well-being of the person, from the notion that medical care focuses upon physiological and psychological well-being, and from the realization that striving for health is a mutual endeavor between physician and patient, most of the basic ethical norms for physicians have been derived over the centuries. The most important of these norms are:
As is true of all ethical norms, these norms for physicians must be applied prudently to particular cases. For example, the norm to tell the truth must be applied in a way that does not cause more harm than good. Telling the truth helps the patient make free decisions about medical care, but in some situations telling the truth could lead to depression on the part of the patient and even suicide. The norms of biomedical ethics are not absolute rules to be followed exactly the same way in every situation. Rather, they are objectives derived from ethical reasoning about the purpose of health care and the patient-physician relationship. Attaining these objectives requires prudence on the part of physicians.
- Allow the patient to assume a personal responsibility for pursuing health. The patient does not become the pawn or the slave of the physician as a result of the medical relationship. Achieving human health in the more extensive meaning of the term involves the use of one's creative functions. Making free choices about health care and other human goods contributes to human fulfillment.
- First of all. do no harm. Physicians are not the only source of human health. In their practice of medicine, they must respect the homeostasis of the physiological system of the person. Moreover, the acts of diagnosis and prognosis are acts of practical science; thus, they are subject to error more so than acts of speculative science.
- Obtain informed consent before medical or surgical procedures are performed. The physiological and psychological well-being of the patient are ordered to social and creative well-being. Only the patient is able to determine what is "good or bad" at this level of function.
- Tell the truth to patients. This not only bespeaks a respect for the patient as person, but also develops an atmosphere of trust.
- Maintain confidentiality concerning detrimental information. Again, the total well-being of the patient must be respected, even though the physician is primarily concerned with physiological and psychological information.
- Respect the bodily integrity of the patient. Problems pertaining to social and creative functions are not solved by manipulating or destroying physiological and psychological functions. Medical and surgical procedures are ethical only if they are directed to achieving improved physiological or psychological function.
- Allow patient to die if therapy to counteract illness or disease imposes a severe burden upon the patient (or family) or is in effective in regard to the purpose of health care taken in its more extensive meaning. Prolonged existence is not the absolute goal of health care. Physiological or psychological well-being may not contribute to the social and creative well-being of the person.
- Practice medicine with a view to effective and equitable use of resources. Each prescribed test or treatment should have an intrinsic relationship to diagnosis and prognosis.
- Care for those who cannot pay for medical services. This norm follows from the nature of the physician's promise and the nature of the basic need on the part of the patient. However, fulfilling this norm involves responsibilities on the part of society as well. Physicians will not be able to solve all problems of health care for the indigent. Moreover, the ability to serve the poor will be balanced by the need of the physician to obtain adequate sustenance and to maintain his or her own responsibilities to professional development for self and dependents.
New Situations and Voices
For the most part, the above-mentioned ethical norms were considered sufficient until after World War I. But in the 1950s and 1960s, the health care situation changed significantly in the United States. Health care became more successful, more expensive, and more often financed by third-party payers or by state and federal governments. As a result of these factors, many voices sought to impose upon physicians new ethical responsibilities, such as the obligations of rationing health care, acting as gatekeepers of the health care system, and providing access to health care to all persons in need. While not offering a complete discussion of this issue, however, it does seem that the social responsibilities arising from our health care system belong to the whole of society, not only to health care professionals. While the social situations that surround the practice of medicine have changed considerably, the essence of ethical medicine remains the same. Thus, as the 21st Century approaches, a physician remains a professional person seeking to help others strive for the vital need of health. Physicians have not become functionaries of the state and therefore must keep a strong sense of their identity in order to avoid becoming confused about their ethical responsibilities as physicians.
Finally, a word concerning the role of two new entities assisting the effort to arrive at ethical medical decisions: the medical ethicist and the institutional ethics committee. As we have indicated, the main participants in ethical decisions concerning health care are the physician and the patient. Physicians and patients (or proxies) both have something to contribute to these decisions. Primarily, the patient or proxy expresses the desires and values of the person seeking medical help. Primarily, the physician makes a diagnosis and designs a medical care program in accord with the expressed values of the patient.. The medical care decision is a cooperative venture based upon the knowledge and skill of the physician and the self-knowledge of the patient.
With this aforementioned description of medical decision making, what role does the medical ethicist or the ethics committee have in medical decision making? Medical ethics is not a new subspecialty within medicine. Physicians, not ethicists or ethics committees, are responsible for ensuring that the ethical perspective is present in medical decisions. Requiring that physicians decide one aspect of patient care and ethicists or ethics committees another aspect is a caricature of both medicine and ethics. Ethicists and ethics committees are able to help physicians prepare for decision making in accord with accepted ethical norms, but they should never replace physicians. While there is a body of knowledge that justifies calling medical ethics a distinct discipline, and thus justifies the role of medical ethicists and ethics committees, there is no reason to posit the medical ethicist or ethics committee as a principal participant in medical decision making. In general, medical ethicists and ethics committees should act as educators of physicians, patients, and families and, in specific cases, as consultants, which is simply a more personal manner of education.
From the foregoing, it is clear that ethical analysis on the part of health care professionals requires serious reflection. The answers to ethical issues are not determined by public opinion or guesswork. Often, the numerous uncertainties of any medical decision make it difficult to arrive at crystal clear decisions. The tenuous character of medical decisions is especially clear in situations where life is in the balance. When should aggressive efforts be increased; when should even non-invasive therapy be withdrawn? But even in less dramatic situations, ethical norms will mandate respectful and considerate patient care. Finally, not only reflective analysis will be required for the practice of ethical medicine but also a sincere desire to help people strive for health will be necessary as well. Reflective reasoning helps health care professionals know ethics; a desire to serve others in their quest for health enables health care professionals to do ethics .
Kevin O'Rourke, OF, JCD, STM, is Director of the Center for Health Care Ethics, St. Louis University Medical Center, St. Louis, Mo.
© Kevin O'Rourke, O.P.