medicine is characterized by its intensive preoccupation with ethical issues.
As medicine advances, it faces new and complex ethical problems, and the
practitioner seeks the help of ethical experts. Yet even among them confusion
reigns, and some issues seem insoluble.
kinds of ethics
One may distinguish between two kinds of medical ethics: Traditional ethics, which deal with the relationship between physician and patient, and modern ethics, which consider also the role of society in this relationship. The first was shaped over the ages and is highlighted by the oath of Hippocrates. The second is a by product of modern medicine. It arose when physicians became involved in human experimentation.
Traditional ethics are simple and straightforward,
and one wonders whether they are really required. One might envision a medical
practice where ethical issues hardly play any role, a medicine without ethics.
Such a putative medicine is described in the first part of this discourse.
Once “Medicine without Ethics” is identified, it will
turn out that many modern medical ethical problems do not belong to
the realm of medicine, and may not concern the practicing physician.
applies a simple technique, or rule of thumb, for distinguishing between
correct and wrong medical statements. If they harm the patient, they are
wrong, and if they aid him, they are correct. Statements that do not affect
patient’s well being, e.g., “Ethics improve your health”,
have to be handled with care. Applying this technique for evaluating modern
medical ethics will reveal that many ethical directives harm the patient.
and other professions
First we ought to examine how other professions handle similar ethical issues. Like the car mechanic who repairs your damaged car. Obviously, the main purpose of medical ethics is to protect the patient from malpractice, which in the case of your car is hardly necessary, since litigation is simpler.
with your mechanic involves an unspoken agreement (contract) that specifies
your request. Once he agreed to meet your demands, he is bound to the contract.
Here is an example of a profession where ethical consideration are not essential.
This silent agreement may be specified more rigorously. The car maker provides a list of parts from which your care is made up. Their condition is defined as state of the machine. You might ask the car mechanic to replace the damaged parts and bring the car back to its undamaged state, which is defined here as repair. Yet repair may not be enough for restoring car performance. Fine-tuning is also required. Performance is viewed here as car health.
A meaningful agreement ought to specify what would be the expected state and health of your machine after treatment. Upon leaving the factory, car health is at its best, and with time it deteriorates. When specifying the expected car health (performance) after treatment, the average (healthy) car deterioration rate ought to be considered.
Might a similar agreement protect the patient against medical malpractice? Unfortunately not, since patient’s state and health are not defined. He therefore turns to traditional medical ethics for his protection, like the oath of Hippocrates (1):
“. . I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to anyone. . . “
Or the Physician's Oath (The World Medical Association, Declaration of Geneva ,1948) (1):
”. . . . I will practice my profession with conscience and dignity; the health of my patient will be my first consideration. . . “
The Oxford dictionary defines malpractice: “Careless illegal, unethical, behavior by somebody in a professional or official position” (2). This definition mentions the measures for protecting yourself against malpractice: Law and ethics.
makes medical treatment different from car repair, is the lack of information
on the patient’s state and health. Suppose now that physicians had
means to measure health. The contract between patient and physician might
be stated unambiguously as follows: “Restore my health”. Like
in the car example, repair or cure may not be enough, and the patient ought
to insist on restoring his health.
Incapable to meet his demand, the physician might answer: "I can not fully restore your health. Following my treatment your health will deteriorate by ten units." The patient may accept this offer, or look for another physician with a better one. After treatment is over, the patient might measure his health and if it does not match the agreement, he may sue his physician. With such a health measure at hand, relying on ethics may not be unnecessary.
new definition of health
A practice of "Medicine without Ethics", requires a new definition of health. Medicine defines health as non-disease, and cure, as disease elimination. Yet health is more than that, it involves also performance. Like in cars, health (performance) continually deteriorates, and cannot be fully restored. Different therapies for the same disease may differ in their effect on patient’s health (3). When specifying his agreement with the physician, the patient ought to demand a cure with the best health outcome.
This health definition is akin to the patient's perception of health. A feeling of ill-health, or dis-ease, drives him to the physician. He cares less about the disease itself, or its cure, he just wants to feel healthy again. This is the meaning of “restore my health”. Many legal and ethical difficulties result from ignoring how treatment affects health.
new health definition provides a simple directive for an adequate treatment:
"Maximize health under the circumstances". Before suggesting a
treatment, the physician will examine all treatment options, and choose
the one with the best health outcome. Given a health measure and a proper
definition of health, it is possible to formulate a contract between patient
and physician, without relying on ethics.
Some problematic ethical issues may be resolved by relying on such an imaginary contract. Should the patient donate his kidney? No, since this would deteriorate his health. For the same reason he may not donate any organ, even if proclaimed clinically dead. Clinical death is defined as brain death, while other organs are still alive, otherwise transplantation would fail. The contract between patient and physician states: "Maximize my health! Which applies to me as a whole. As long as some organs are viable you have to continue trying!". Not the "Sanctity of life" precludes the physician from advising his patient to donate his organs, but a simple contract, that requires him to maintain patient’s health.
physician cannot accept a demand to kill his patient even if the latter
is extremely ill, and with no recovery in sight. His job is to improve health,
and not to destroy it. For the same reason the car mechanic will refuse
to destroy your car, and refer you to demolition experts.
Modern medicine launched a new kind of physician, the experimentalist. During the 19th century, and in the beginning of the 20th century, medical research was done in vitro (biochemistry), on corpses (pathology), and on laboratory animals (microbiology, and physiology). Human experimentation was uncommon. The Nazi regime encouraged human experimentation for ideological purposes. Usually, non academic physicians had little access to human experimentation, since they lacked the expertise of academic physicians. Although all took the oath of Hippocrates, academic physicians preferred to ignore it. They eagerly explored “secrets of life” that could be revealed only in humans, e.g., the physiological manifestation of torture.
Fortunately Nazi Germany was defeated, yet the thrill accompanying human experimentation prevailed. Instead of banning it altogether, the academia searched for means to allow it. The Nuremberg code (4) is an attempt to justify human experimentation by introducing society as a partner in the agreement between physician and patient.
Nuremberg code (4)
the heading of "Permissible human experiments" we find that "The
protagonists of the practice of human experimentation justify their views
on the basis that such experiments yield results for the good of society".
The rest of the document contains ten principles that must be satisfied
in order to protect the patient. The first is the most problematic: "Voluntary
consent of the human subject is absolutely essential", and
the patient "should have sufficient knowledge and comprehension
of the elements of the subject matter involved as to enable him to make
an understanding and enlightened decision."
Imagine that car repair would involve a similar consent would you sign it? More, imagine that your car mechanic, concerned with the greenhouse effect of your car, decides to protect the environment and society, by mounting in your car an environment-protective-part that might affect its performance. Would you consent? You would sue him! If society finds such measures important they ought to be covered by law. The same applies to human experimentation.
By its very nature, any experiment done on a patient may weaken his health. Like phase-1 trials for cancer drugs, which are designed to determine drug toxicity (5). Which physician might honestly suggest his patient to enroll in such a trial? Yet experts in medical ethics urge him to do so.
How serious is the requirement that the patient "should have sufficient knowledge and comprehension. . ." Apart from the designers of clinical trials, even competent physicians do not understand all their intricacies. What is the merit of understanding the trial's purpose and danger, when health deterioration is hardly ever mentioned? And yet, to preserve his autonomy, the patient is urged to actively participate in a decision process which he barely understands. If society finds clinical trials important for general health, let it legislate an appropriate law, relieving the physician from misleading his patient.
double loyalty of the physician
The term “Clinical death”
was defined by the society for assisting its members who need new organs.
From the medical perspective it is a fake definition. Death is an end point
and does not proceed in steps. Why not add “Clinical death”
to other legal definitions e.g., when life starts? Only the society
has the power to decide when to kill a patient in order to obtain his organs,
and not the physician.
If the society finds that mercy-killing
is justified, it may train mercy-killers, with their own oath, and relieve
the physician from this task.
The double loyalty of the physician, to his patient and to society is the main reason for the complexity of medical ethics. On one hand he is bound to his patient by a contract, while on the other, society requires him to breach it. Double loyalty results in the morbid pre-occupation of medicine with ethical issues (6). It is not intended here to belittle the gravity of ethical issues. They simply do not belong to the domain of medicine, and ought to be dealt with by the society. Many life and death issues, e.g., when killing is murder, or an heroic act of war, lie outside the scope of medicine, and so does human experimentation. The medical profession may be competent to experiment on humans, yet the justification of human experiments is beyond its scope, since most experiments endanger the patient.
The latest developments in the ethics of human experimentation are summarized in this document. The following excerpts highlight the conflict between physician's duty to his patient and to society.
§1. "The World Medical Association has developed the Declaration of Helsinki as a statement of ethical principles to provide guidance to physicians and other participants in medical research involving human subjects".
document starts with the traditional commitment of the physician to his
patient: §3. "The health of my patient will be my first
consideration". It then turns to the duty of the physician to
society: §4. "Medical progress is based on research which ultimately
must rest in part on experimentation involving human subjects".
§19. "Medical research is only justified if there is a reasonable
likelihood that the populations in which the research is carried
out stand to benefit from the results of the research".
Guideline §21 implicitly acknowledges the risk involved to the patient, and urges the physician: "To minimize the impact of the study on the subject's physical and mental integrity and on the personality of the subject". How can a physician who is committed to his patient advise him to participate in a risky trial even if its negative impact is minimized?
§11 states that: "Medical research involving human subjects must conform to generally accepted scientific principles."
scientific principles underlying phase-3 clinical trials clearly harm the
patient (6). In these trials, sick individuals are divided into two groups.
Members of the "control group" are treated with an effective drug,
while the rest receive the new drug whose effect is still unknown. Each
patient is randomly assigned to one of the groups. A coin is flipped, and
if its face is up, the patient is assigned to one group, otherwise to the
other. This selection process, known as randomization, violates §3.
"The health of my patient will be my first consideration",
since the physician relinquishes his duty to the fate. What is
the significance of an informed consent if the patient does not know in
which group he will be enrolled? Helsinki declaration ignores randomization.
Applying the rules of thumb for distinguishing between correct and wrong medical-ethical statements, will reveal that most of them are wrong, since they harm the patient. This is felt also by the patient, who seeks advice and guidance, while ethicists advise him to decide by himself. Guidance is regarded as paternalistic and should be avoided. He then turns to alternative medicine, where ethics seem much simpler. Healers do not experiment, they try to help and guide. This is the main appeal of alternative medicine. It is committed to the patient and society does not interfere in this relationship.
The patient is best served by a physician who adheres to traditional ethics. There ought to be only one ethical code, unfortunately there are two (6). Medical specialists prefer the other ethical code. When the patient seeks their help, he is exposed to the danger of modern ethics and needs an adviser. The general practitioner ought to resume his time honored duty as adviser. Since modern medical practice became so complicated, he ought to be familiar with the intricacies of modern medicine. This new kind of general practitioner is known as academic generalist (8,9).
The generalist represents his patient in Medicine, like a lawyer in court. He advises him in all steps of his decision process, suggests the best treatment options, accompanies him to the medical center, and oversees the activities of specialists.
1. Yanofsky CS, Heck AW, Vickery JL, Janton FJ, Diebert L.
Catalogue of Physician's Oaths/
Hornby AS. Oxford advanced learners dictionary. 4th Ed. Oxford
University Press 1989.
3. Zajicek G. What is health?
4. THE NUREMBERG CODE [from Trials of War Criminals before the Nuremberg Military Tribunals under Control Council Law No. 10. Nuremberg, October 1946 - April 1949.
Washington D.C.: U.S. G.P.O, 1949-1953.
5. Sugerman J. Ethical Considerations in Leaping from Bench to Bedside” Science 1999; 285 : 2071.
6. Zajicek G. Medical Ethics: Two codes of ethics in Medicine
The Cancer J. 1995;8:226-227.
7. World medical association declaration of Helsinki
Ethical Principles for Medical Research Involving Human Subjects Adopted by the 18th WMA General Assembly
Helsinki, Finland, June 1964.
8. Zajicek G. Doctors and healers
9. Zajicek G. Benefits of primary care. Letter to the editor
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