Introduction
In the past two centuries, enormous advances in medicine and science have been achieved. The law has not been able to keep up with scientific breakthroughs and increased instances of novel medical technologies (Beauchamp & Childress, 2001). The subsequent debates bordering on religious and moral issues have given rise to the development of a medical ethics discipline. Medical ethics “can be described as a system of moral principles that apply values and judgments to medical practice” (Bekelman, 2003). Medical ethics takes into account the practical reality found in a clinical setting and links it to philosophy, sociology and theology, to establish a code of conduct (Toulmin, 1992). The situation has led to policy dilemmas, especially in regard to cases where an informed decision requires ethical concerns, in addition to legal and economic considerations (Lakhan, Hamlat, & McNamee, 2009). According to history, Western medical ethics was developed from ancient guidelines on the responsibilities of physicians which include religious teachings and the Hippocratic Oath. The first biomedical code was formulated in the 5th century in the Ostrogothic Empire (Berlant, 1975).
Due to their special skills and knowledge, medical professionals have the responsibility of improving and maintaining the health status of their patients who, might be faced with certain risks because of their illness or want to maintain their health (Beauchamp & Childress, 2001). Over the centuries, progress has been made on the body of principles intended to guide doctors on how they should behave towards patients, colleagues and the society.
This paper seeks to conduct a broad examination of the Medical Ethics discipline in the United States. The paper will specifically address the relevance of medical ethics from a health policy standpoint; historical and present deliberations; successes and failures of various ethical programs; the major stakeholders involved; and social and ethical perspectives. At the end of the paper, recommendations will be given on health reforms and policy solutions.
History and social dimensions of Medical ethics in the United States
The Original code of medical ethics in the United States was established in 1847 (the first in the world), following deliberations by the National Medical convention held in New York City and Philadelphia (Beauchamp & Childress, 2001). The code of ethics benchmarked medical practice onto moral and religious requirements. The early ethics were mainly concerned with medical quackery, administration of proper medication and morally correct practices. The medical ethics followed the establishment of the American Medical Association (AMA).
Faced with new challenges in the medical practice, the American Medical Association promulgated a suggestive advisory document on the principles of Medical Ethics in 1903. The document was approved by the House of Delegates and outlined the following: the duties of physicians to their patients; the duties of physicians to each other and to the medical profession at large; and the duties of the medical profession to the public (Toulmin, 1992).
During the 19th century and the first half of 20th century, the nature of medicine practiced was not controversial enough to attract arguments from a religious and moral perspective. New techniques and technologies
The Early in 1950s it was found that the medical profession in the United States had become too technical to the point of losing moral concerns. The bureaucratic clinical settings found in hospitals played a major role in the depersonalization if medicine. The so called the “unacknowledged legislators of mankind” such as Joseph Fletcher and Paul Ramsey were the first people to see the moral problems that were facilitated by the change in medical institutions (Toulmin, 1992). Such people were particularly concerned with the notion that physicians were left to decide treatment choices with far reaching ramifications. Most of the theological issues that were being raised could not be dismissed by doctors as irrelevant, or criticized for being politically motivated. The debates that followed led to the establishment of a new field referred to as bioethics. The term “bioethics” was coined by “Rensselaer Porter, a cancer research” (Tassano, 1995). Originally, the word bioethics was seen to include ethics in all biological sciences such as ecology and agriculture in addition to medicine and health. It did not take long before moral theologian began writing on the topic. American Medical Association revised the principle of medical ethics twice in the 1950s. The 47 sections adopted in 1955 were reduced to 10 in 1957.
Changes in nearly all aspects of human existence were made during the period between 1965 and 1975, and medical ethics was not left behind. Indeed, the late 1960s and early 1970s marked an important point in the way people viewed medical innovation and biomedical research. Research on human subjects reached its boiling point in the United States with the revelation of the Tuskegee syphilis study (Ryan, 2010). Other abuses that were reported during that period included the injection of liver cancer cells into patients at the Jewish Chronic Disease hospital in Brooklyn, and the intentional infection of residents of Willow brook State School for the Retarded with Hepatitis virus (Jordan, 1998).
In the period before 1960, politics in America was based on consensus in the sense that policy issues were still concerned with the most efficacious means of achieving national goals. Debates about medicine often led to the phrase “doctors know the best” (Tassano, 1995). In consistence with the Cultural Revolution that was witnessed in the 1960s, bioethics was one of the areas in which the government was required to address the outstanding issues. This required a new direction in which the issues raised in biomedical research and medical technology were to be dealt with in a secular manner consistent with pluralism (Everette, Perry, Warner, Chapman, & Zaner, 2012). In the 1960s, the use begun to experience a shift towards politics of sectional interests, as different groups started to realize that they required special needs. By 1970 the assumption that professionals, including doctors, will be true to their calling was significantly weakened. There was no framework for legislators to control medical consultations offered by private clinicians. So, it was not a shock to anyone when a national commission to “protect” human subjects of biomedical and behavioral research was set up by the Congress in 1974 (Lakhan, Hamlat, & McNamee, 2009). Indeed, the systems of assurances to subjects of biomedical research at major research institutions and universities had been started in 1967. Biomedical research was and still being spearheaded by the National Institute of Health (NIH). Congress had long controlled the budget of NIH and, therefore, the institute had established a system of “assurances” through which all research proposals involving the use of human subjects were subjected to ethical review by “institutional review boards” (Toulmin, 1992).
In the years that followed various public meetings were organized to discuss moral problems in various medical disciplines. The public even required some practices such as psychosurgery to be denounced all together. By late 1970s, most physicians and biomedical scientists increasingly became unhappy with the wave of public criticism. The social, political and moral critique of medicine was seen by some as an intrusion into the proper business of medical profession (Bekelman, 2003).
By the 1980s, the atmosphere had cooled considerably; questions of medical ethics were now being addressed with more theoretical emphasis. The moral questions that had been raised by theologians in the 1950s were now restated in a more philosophical way (Lakhan, Hamlat, & McNamee, 2009). With increased intellectual focus, the debates shifted from the Congress to universities and other institutions. The abstract and general terms that were now being used in these debates were borrowed from the 20th century moral philosophy (Ryan, 2010). Important moral issues arising in clinical medicine, medical research, and the general delivery of health services, were refocused into theoretical categories of moral philosophy (Beauchamp & Childress, 2001).
In 1980s, it became apparent that there was a wide gap between the particular issues of practice that needed to be addressed and the abstract, universal issues of theory that had been advanced by moral philosophers. Health professionals who had begun to take courses in “applied ethics” found the philosophical analysis to be too general for the realities in the clinical setting. Therefore, several clinical centers across United States began to develop ways of addressing the moral problems in clinical practice. For instance, “ethics consultation service” was experimented in various medical disciplines such as cardiology, neurology and psychiatry (Ryan, 2010).
With more and more debates, it became apparent that the correct course was to give the responsibility of making painful decisions to patients or their families, supported by religious advisers and non-medical counselors. This ensured the reintegration of moral aspects into clinical medicine while at the same time giving outsiders the chance to comment and criticize (Lakhan, Hamlat, & McNamee, 2009).
The clamor for the medical profession continued into the 1990s and 2000s and is still much present today. Government deliberations and efforts by other bodies such as AMA have ensured the adoption of an ethical framework for majority of practices in framework. AMA has also consulted the constitutional provision on human rights to develop policies for topics that are hotly contested. Such topics may include abortion, stem cell research, and assisted suicide among others. It is important to note that though such topics are still being debated in political and social circles, the positions taken by AMA are legally binding and are subject to revision with the advancement of medical practice.
Medical ethical framework and stakeholders in the United States
As shown in the historical analysis, “ethical analysis has evolved into a useful tool for the evaluation and governance of new technologies, and Congress has had a long interest in Bioethics” (Berlant, 1975). The major players in the formulation of Medical ethics include the following: Federal government, AMA, State governments, branches of medicine, the society of bioethics, president’s council of bioethics, the philosophical association, among others (Beauchamp & Childress, 2001). The above mentioned players have worked hard to establish a common ground that takes into account all views and concerns. Medical ethics in the United States is overseen by American Medical Association (AMA). Therefore, AMA has outlined the principles of medical ethics and has outlined all opinions or various aspects of the medical profession. The opinions revolve around the following: “social policy issues; inter-professional relations; hospital relations; confidentiality and communications; medical charges; doctor records; practice matters; professional rights and responsibilities; and patient physician relationships” (Brody, 1998). The interest of the Federal government to integrate bioethics into policy and decision making is founded in the desire to understand the ethics surrounding the support for particular types of research, and the delivery of services in Federal programs such as Medicare and Medicaid (Bekelman, 2003).
Stakeholders
In regard to stake in the ethical decision being made, stakeholders are can be varied and many. For instance in regard to the Willow brook hepatitis studies the stakeholders were the children who were to be tested on, their parents, the researchers and the society (Beauchamp & Childress, 2001). Patients or subjects in a medical study are regarded as stakeholders because there is a direct health risk with one or all of the decisions that will be made by researchers or physicians. Families are stakeholders because the well-being of one of their own is of utmost interest to them. The medical or other institution where the treatment or research is being carried out is a stakeholder because it is liable for the wellbeing of subjects or patients under its care. The society is a major stakeholder because it will directly benefit from the medical study that is being carried out in one or more if its members. The process of identifying stakeholders often considers how they will be affected or why they consider themselves to be stakeholders. On many occasions, disagreements are usually witnessed between stakeholders. If such a situation arises then it becomes important to establish the reasons that exist that would give priority to the interests of one party over the other (Ryan, 2010). Additionally, it becomes important to determine whoever is vested with the authority to make the decision (Jordan, 1998).
Summary of AMAs ethical principles
Currently, the medical profession subscribes to a body of ethical statements that have developed primarily to benefit the patient. Healthcare providers are required to recognize the responsibilities to their patients as a first priority, in addition to the society, other healthcare professionals (Beauchamp & Childress, 2001). The ethical principles that have been adopted by AMA are not laws, but standards of practice that define the requirements of worthy medical practice (Jordan, 1998).
The first section of the ethical principles states that “physicians should dedicate themselves to the provision of expert medical care, with compassion and respect for human dignity and rights” (Beauchamp & Childress, 2001). The second section requires a physician to “uphold the standards of professionalism, be honest in the course of professional interaction, and be able to report all physicians engaging in inappropriate practice” (Lakhan, Hamlat, & McNamee, 2009). The third section requires the physician to respect “the law and be able to make changes that are in the best interest of the patient” (Beauchamp & Childress, 2001). The forth section requires physicians to “respect the rights of patients, including the right to confidentiality, in addition to the rights of other healthcare professionals within the provisions of the law”. The fifth section requires physicians to “continue undertaking studies and advance scientific knowledge maintain commitment to medical education, make relevant information available to patients, colleagues, and the public” (Lakhan, Hamlat, & McNamee, 2009). The sixth section allows physicians to “choose whom to serve and associate with in the course of providing appropriate patient care, except in emergency situations” (Jordan, 1998). The 7th section confers physicians with the responsibility to “actively participate in activities that are aimed at improving the community and betterment of public health” (Bekelman, 2003). The 9th section requires the physician to regard the responsibility to the patient as principal. The 9th section requires physicians to assist all people in accessing medical care (Beauchamp & Childress, 2001).
Medical ethics policies in the United States
In general terms, law and medical ethics overlap significantly (Berlant, 1975). Both disciplines address similar concepts in healthcare delivery. The following areas are equally addressed in the law and medical ethics: the freedom to access medical care; the requirement to seek informed consent; the need for confidentiality; privileged communication with physicians; abortion; and assisted suicide (Toulmin, 1992).
The most important role played by policies in ethical decision making is to the evaluation and determination of the person who is vested with the authority to make a decision. Knowledge, risk and moral values regarding a given case are often considered to determine the authority of a particular stakeholder in decision making. For instance, “the legal and ethical doctrine of informed consent gives participants the right to make the decision whether or not to participate in a research” (Bekelman, 2003).
Social policies can be described as guidelines, principles, legislations and other activities that directly affect living conditions of humans (Brody, 1998).
Policies on medical ethics are formulated for specific areas in medical practice. The policies are revised from time to time to reflect the advances in medical research and the outcomes of on-going debates on contentious issues. The AMA House of Delegates has developed medical ethical policies that touch on several aspects of the medical ethics (Brody, 1998). The terms used by AMA to describe the policies are not necessarily medical terms. This section explores some ethical policies, particularly those on practices that have created ethical dilemmas in the past.
Ethical policy on abortion
Abortion is described as the termination of pregnancy and is often conducted by expulsion of a fetus (Bekelman, 2003). AMA policy on abortion recognizes the right to abortion that features in the US constitution. Personal values and beliefs are used to decide whether abortion should be carried out or not. The policy states that pregnancy termination can only be carried out by physicians who have been trained appropriately (Beauchamp & Childress, 2001). AMA takes into account the fact that there might be other parties who have adopted a different position and, therefore encourages them to comply. In a separate clause, AMA cautions various parties from inaccurate reporting on the abortion policy to reduce public misconceptions. AMA states that fetal tissue that has been obtained following an induced abortion can be used for legitimate scientific research purposes, including stem cell transplantation individuals who seek to procure an abortion have a right to privacy (Jordan, 1998)..
Ethical Policy on the freedom of communication between physicians and patients
Through this policy, AMA strongly condemns interference from government or any other third party that affects a physician’s judgment on the kind of information and treatment that might be provided in the patient’s best interest (Beauchamp & Childress, 2001).
Policy on violence against Medical Facilities and Health Care Practitioners and Their families
AMA strongly supports the right for individuals to access medical care and opposes the use of violence to intimidate physicians and other healthcare providers. It also opposes violence that is directed towards medical facilities including abortion and family planning centers and clinics.
Policy on End of life care
The policy on end life states that physicians are under no obligation to deliver care has a reasonable chance of benefiting the patient, even if it is in the best interest of their professional judgment (Toulmin, 1992). However, if the patient in case is seriously disabled then the physician should consider the best option for that particular patient. AMA does not support physician assisted suicide because the practice contradicts the physician’s principle role of curing (Beauchamp & Childress, 2001). However, there are legal frameworks in the United States that can be used to evaluate the need for a physician assisted suicide.
Problems encountered in the implementation of medical ethics
How ethical problems arise
Ethical problems are usually regarded as invitations to further reflections. In practice, ethical issues are often seen to occur on three ways: social, volitional and cognitive (Ryan, 2010). Most ethical dilemmas are volitional due to the fact that there are powerful motives or interests that lead medical professionals to do what is not right (Ryan, 2010). In fact, the matter of conflicting interests has been a major source of debate in the recent past. In some cases, physicians are faced with dilemmas of making the right choice. For instance, it might be apparent that a patient has made wrong choice and the physician has to violate his/her rights in order to help or a number of choices might be available to a physician, all of which are harmful and he/she is required to make a decision. In some cases, the physician might be certain that this is the right thing to do and be willing to do it, but the decision is socially unpopular due to a disagreement between stakeholders (Tassano, 1995).
Ethical problems arise when stakeholder has a legitimate claim to competing decisions or when the decision making authority is not clear in a specific way (Everette, Perry, Warner, Chapman, & Zaner, 2012). Resolution to such dilemmas is often achieved through the examination of statutes, regulations, and cases, in addition to professional codes (Lakhan, Hamlat, & McNamee, 2009)
There has been an argument that conventional medical ethics is biased by assuming a framework in which individuals are free to contract with one another to determine and provide a treatment method determined by the ability to pay (Bekelman, 2003). There is a divergence that exists between the wishes of patients and the preference of medical practitioners and other stakeholders (Ryan, 2010). Many analysts have observed that interests of the state and suppliers usually override those of patients.
Outstanding areas
Outstanding ethical issues have been raised in the following areas: Abortion, assisted suicide, life support, surrogate motherhood and stem cell research (Tassano, 1995). The arguments that have resulted from the above areas cannot be addressed by the existing ethical framework.
Conclusions
This paper sought to conduct a broad examination of medical ethics discipline in the United States. Several areas were covered in this examination and the include the history and social dimensions of medical ethics in the United States; Medical ethical framework; medical ethical policies and the various challenges that are faced in the implementation of medical ethics. The paper has established that there are outstanding areas that need to be ironed out and, therefore, recommends more efforts by the different stakeholders to ensure that a common ground is achieved.
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