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Medical ethics is primarily a field of applied ethics, the study of moral values and judgments as they apply to medicine.As a scholarly discipline, medical ethics encompasses its practicalapplication in clinical settings as well as work on its history,philosophy, theology, and sociology.
Medical ethics tends to be understood narrowly as an applied professional ethics, whereas bioethics appears to have worked more expansive concerns, touching upon the philosophy of science and the critique of biotechnology.Still, the two fields often overlap and the distinction is more amatter of style than professional consensus. Medical ethics shares manyprinciples with other branches of healthcare ethics, such as nursing ethics.
There are various ethical guidelines. The Declaration of Helsinki is regarded as one of the most authoritative.[1]
By the 18th and 19th centuries, medicalethics emerged as a more self-conscious discourse. For instance,authors such as the British Doctor Thomas Percival (1740-1804) of Manchesterwrote about "medical jurisprudence" and reportedly coined the phrase"medical ethics." Percival's guidelines related to physicianconsultations have been criticized as being excessively protective ofthe home physician's reputation. Jeffrey Berlant is one such critic whoconsiders Percival's codes of physician consultations as being an earlyexample of the anti-competitive, "guild"-like nature of the physiciancommunity.[2][3] In 1847, the American Medical Association adopted its first code of ethics, with this being based in large part upon Percival's work [2]. While the secularized field borrowed largely from Catholic medical ethics, in the 20th century a distinctively liberal Protestant approach was articulated by thinkers such as Joseph Fletcher. In the 1960s and 1970s, building upon liberal theory and procedural justice, much of the discourse of medical ethics went through a dramatic shift and largely reconfigured itself into bioethics.[4]
Since the 1970s, the growing influence of ethics in contemporary medicine can be seen in the increasing use of Institutional Review Boards to evaluate experiments on human subjects, the establishment of hospital ethics committees, the expansion of the role of clinician ethicists, and the integration of ethics into many medical school curricula.[5]
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1 Values in medical ethics

1.1 Autonomy
1.2 Beneficence
1.3 Non-Maleficence

1.3.1 Double effect

2 Informed consent
3 Confidentiality
4 Criticisms of orthodox medical ethics
5 Importance of communication
6 Ethics committees
7 Cultural concerns

7.1 Truth-telling
7.2 Online Business Practices

8 Conflicts of interest

8.1 Referral
8.2 Vendor relationships
8.3 Treatment of family members
8.4 Sexual relationships

9 Futility
10 Further reading
11 See also

11.1 Reproductive medicine
11.2 Medical research
11.3 Famous cases in medical ethics
11.4 Distribution and utilization of research and care

12 Sources and References
13 External links

[edit] Values in medical ethics
In the United Kingdom, General Medical Council provides clear overall modern guidance in the form of its 'Good Medical Practice' statement. Other organisations, such as the Medical Protection Society and a number of university departments, are often consulted by British doctors regarding issues relating to ethics.
How does one ensure that appropriate ethical values are being applied within hospitals? Effective hospital accreditationrequires that ethical considerations are taken into account, forexample with respect to physician integrity, conflicts of interest,research ethics and organ transplantation ethics.
[edit] Autonomy
Autonomy is a general indicator of health.Many diseases are characterised by loss of autonomy, in variousmanners. This makes autonomy an indicator for both personal well-being,and for the well-being of the profession. This has implications for theconsideration of medical ethics: "is the aim of health care to do good,and benefit from it?"; or "is the aim of health care to do good toothers, and have them, and society, benefit from this?". (Ethics - bydefinition - tries to find a beneficial balance between the activitiesof the individual and its effects on a collective.)
By considering Autonomy as a gaugeparameter for (self) health care, the medical and ethical perspectiveboth benefit from the implied reference to Health.
[edit] Beneficence
James Childress and Tom Beauchamp in Principle of Biomedical Ethics (1978) identify beneficence as one of the core values of health care ethics. Some scholars, such as Edmund Pellegrino, argue that beneficence is the onlyfundamental principle of medical ethics. They argue that healing shouldbe the sole purpose of medicine, and that endeavors like cosmetic surgery, contraception and euthanasia fall beyond its purview.
[edit] Non-Maleficence
In practice, however, many treatmentscarry some risk of harm. In some circumstances, e.g. in desperatesituations where the outcome without treatment will be grave, riskytreatments that stand a high chance of harming the patient will bejustified, as the risk of not treating is also very likely to do harm.So the principle of non-maleficence is not absolute, and must be balanced against the principle of beneficence (doing good).
Some American physicians interpret this principle to exclude the practice of euthanasia,though not all concur. Probably the most extreme example in recenthistory of the violation of the non-maleficence dictum was Dr. Jack Kevorkian,who was convicted of second-degree homicide in Michigan in 1998 afterdemonstrating active euthanasia on the TV news show, 60 Minutes.
In some countries euthanasia is acceptedas standard medical practice. Legal regulations assign this to themedical profession. In such nations, the aim is to alleviate thesuffering of patients from diseases known to be incurable by themethods known in that culture. In that sense, the "Primum no Nocere" isbased on the realisation that the inability of the medical expert to offer help, creates a known great and ongoing suffering in the patient."Not acting" in those cases is believed to be more damaging thanactively relieving the suffering of the patient. Evidently the abilityto offer help depends on the limitation of what the practitioner cando. These limitations are characteristic for each different form ofhealing, and the legal system of the specific culture. The aim to "notdo harm" is still the same. It gives the medical practitioner aresponsibility to help the patient, in the intentional and activerelief of suffering, in those cases where no cure can be offered.
"Non-maleficence" is defined by itscultural context. Every culture has its own cultural collectivedefinitions of 'good' and 'evil'. Their definitions depend on thedegree to which the culture sets its cultural values apart from nature.In some cultures the terms "good" and "evil" are absent: for them thesewords lack meaning as their experience of nature does not set themapart from nature. Other cultures place the humans in interaction withnature, some even place humans in a position of dominance over nature.The religions are the main means of expression of these considerations.
Depending on the cultural consensusconditioning (expressed by its religious, political and legal socialsystem) the legal definition of Non-maleficence differs. Violation ofnon-maleficence is the subject of medical malpractice litigation. Regulations thereof differ, over time, per nation.
[edit] Double effect
Some interventions undertaken byphysicians can create a positive outcome while foreseeably, butunintentionally, doing harm. The combination of these two circumstancesis known as the "double effect." A commonly cited, but fallacious,example of this phenomenon is the use of morphine in the dying patient.Such use of morphine can ease the pain and suffering of the patient,while simultaneously hastening the demise of the patient throughsuppression of the respiratory drive. If correct, this would be anexample of the double effect; however, no research evidence supportsthe claim that appropriately administered opioid drugs depress therespiratory system.[6]
[edit] Informed consent
Main article: Informed consent
Informed consentin ethics usually refers to the idea that a person must befully-informed about and understand the potential benefits and risks oftheir choice of treatment. An uninformed person is at risk ofmistakenly making a choice not reflective of his or her values orwishes. It does not specifically mean the process of obtaining consent,nor the specific legal requirements, which vary from place to place,for capacity to consent. Patients can elect to make their own medicaldecisions, or can delegate decision-making authority to another party.If the patient is incapacitated, laws around the world designatedifferent processes for obtaining informed consent, typically by havinga person appointed by the patient or their next-of-kin make decisions for them. The value of informed consent is closely related to the values of autonomy and truth telling.
A correlate to "informed consent" is the concept of informed refusal.
[edit] Confidentiality
Main article: Confidentiality
Confidentialityis commonly applied to conversations between doctors and patients. Thisconcept is commonly known as patient-physician privilege.
Legal protections prevent physicians from revealing their discussions with patients, even under oath in court.
Confidentiality is mandated in America by HIPAAlaws, specifically the Privacy Rule, and various state laws, some morerigorous than HIPAA. However, numerous exceptions to the rules havebeen carved out over the years. For example, many states requirephysicians to report gunshot wounds to the police and impaired driversto the Department of Motor Vehicles. Confidentiality is also challengedin cases involving the diagnosis of a sexually transmitted disease in apatient who refuses to reveal the diagnosis to a spouse, and in thetermination of a pregnancy in an underage patient, without theknowledge of the patient's parents. Many states in the U.S. have lawsgoverning parental notification in underage abortion.[3]
Traditionally, medical ethics has viewedthe duty of confidentiality as a relatively non-negotiable tenet ofmedical practice. More recently, critics like Jacob Appel have arguedfor a more nuanced approach to the duty that acknowledges the need forflexibility in many cases.[7]
[edit] Criticisms of orthodox medical ethics
It has been argued that mainstream medicalethics is biased by the assumption of a framework in which individualsare not simply free to contract with one another to provide whatevermedical treatment is demanded, subject to the ability to pay. Because ahigh proportion of medical care is typically provided via the welfarestate, and because there are legal restrictions on what treatment maybe provided and by whom, an automatic divergence may exist between thewishes of patients and the preferences of medical practitioners andother parties. Tassano[8]has questioned the idea that Beneficence might in some cases havepriority over Autonomy. He argues that violations of Autonomy moreoften reflect the interests of the state or of the supplier group thanthose of the patient.
Routine regulatory professional bodies or the courts of law are valid social recourses.
[edit] Importance of communication
Many so-called "ethical conflicts" in medical ethics are traceable back to a lack of communication.Communication breakdowns between patients and their healthcare team,between family members, or between members of the medical community,can all lead to disagreements and strong feelings. These breakdownsshould be remedied, and many apparently insurmountable "ethics"problems can be solved with open lines of communication.[citation needed]
[edit] Ethics committees
Often, simple communication is not enoughto resolve a conflict, and a hospital ethics committee must convene todecide a complex matter.
These bodies are composed primarily of health care professionals, but may also include philosophers, lay people, and clergy - indeed, in many parts of the world their presence is considered mandatory in order to provide balance.
With respect to the expected composition of such bodies in the USA, Europe and Australia, the following applies [4].
U.S. recommendations suggest thatResearch and Ethical Boards (REBs) should have five or more members,including at least one scientist, one non-scientist and one person notaffiliated with the institution. The REB should include peopleknowledgeable in the law and standards of practice and professionalconduct. Special memberships are advocated for handicapped or disabledconcerns, if required by the protocol under review.
The European Forum for Good ClinicalPractice (EFGCP) suggests that REBs include two practicing physicianswho share experience in biomedical research and are independent fromthe institution where the research is conducted; one lay person; onelawyer; and one paramedical professional, e.g. nurse or pharmacist.They recommend that a quorum include both sexes from a wide age rangeand reflect the cultural make-up of the local community.
The 1996 Australian Health EthicsCommittee recommendations were entitled, "Membership Generally ofInstitutional Ethics Committees". They suggest a chairperson bepreferably someone not employed or otherwise connected with theinstitution. Members should include a person with knowledge andexperience in professional care, counselling or treatment of humans; aminister of religion or *****alent, e.g. Aboriginal elder; a layman; alaywoman; a lawyer and, in the case of a hospital-based ethicscommittee, a nurse.
The assignment of philosophers or religious clerics will reflect the importance attached by the society to the basic values involved. An example from Sweden with Torbjörn Tännsjö on a couple of such committees indicates secular trends gaining influence.
[edit] Cultural concerns
Culture differences can create difficultmedical ethics problems. Some cultures have spiritual or magicaltheories about the origins of disease, for example, and reconcilingthese beliefs with the tenets of Western medicine can be difficult.
[edit] Truth-telling
Some cultures do not place a greatemphasis on informing the patient of the diagnosis, especially whencancer is the diagnosis. Even American culture did not emphasizetruth-telling in a cancer case, up until the 1970s. In Americanmedicine, the principle of informed consent takes precedence over other ethical values, and patients are usually at least asked whether they want to know the diagnosis.
[edit] Online Business Practices
The delivery of diagnosis online leadspatients to believe that doctors in some parts of the country are atthe direct service of drug companies. Finding diagnosis as convenientas what drug still has patent rights on it. Physicians and drugcompanies are found to be competing for top ten search engine ranks tolower costs of selling these drugs with little to no patient involvement[9]
[edit] Conflicts of interest
Physicians should not allow a conflict ofinterest to influence medical judgment. In some cases, conflicts arehard to avoid, and doctors have a responsibility to avoid entering suchsituations. Unfortunately, research has shown that conflicts ofinterests are very common among both academic physicians[10] and physicians in practice[11]. The The Pew Charitable Trusts has announced the Prescription Projectfor "academic medical centers, professional medical societies andpublic and private payers to end conflicts of interest resulting fromthe $12 billion spent annually on pharmaceutical marketing".
[edit] Referral
For example, doctors who receive incomefrom referring patients for medical tests have been shown to refer morepatients for medical tests [12]. This practice is proscribed by the American College of Physicians Ethics Manual [13].
Fee splittingand the payments of commissions to attract referrals of patients isconsidered unethical and unacceptable in most parts of the world -while it is rapidly becoming routine in other countries, like India,where many urban practitioners currently pay a percentage ofoffice-visit charges, lab tests as well as hospital care tounaccredited "quacks", or semi-accredited "practitioners of alternativemedicine", who refer the patient. It is tolerated in some areas of USmedical care as well.
[edit] Vendor relationships
Studies show that doctors can be influenced by drug company inducements, including gifts and food. [14] Industry-sponsored Continuing Medical Education (CME) programs influence prescribing patterns. [15] Many patients surveyed in one study agreed that physician gifts from drug companies influence prescribing practices. [16]A growing movement among physicians is attempting to diminish theinfluence of pharmaceutical industry marketing upon medical practice,as evidenced by Stanford University's ban on drug company-sponsoredlunches and gifts. Other academic institutions that have bannedpharmaceutical industry-sponsored gifts and food include the Universityof Pennsylvania, and Yale University. [17]
[edit] Treatment of family members
Many doctors treat their family members.Doctors who do so must be vigilant not to create conflicts of interestor treat inappropriately.[18][19].
[edit] Sexual relationships
Sexual relationships between doctors and patients can create ethical conflicts, since sexual consent may conflict with the fiduciaryresponsibility of the physician. Doctors who enter into sexualrelationships with patients face the threats of deregistration andprosecution. In the early 1990s it was estimated that 2-9% of doctorshad violated this rule[20].Sexual relationships between physicians and patients' relatives mayalso be prohibited in some jurisdictions, although this prohibition ishighly controversial.[21].
[edit] Futility
The concept of medical futility has beenan important topic in discussions of medical ethics. What should bedone if there is no chance that a patient will survive but the familymembers insist on advanced care? Previously, some articles definedfutiliy as the patient having less than a one percent chance ofsurviving. Some of these cases wind up in the courts. Advanceddirectives include living wills and durable powers of attorney for health care. (See also Do Not Resuscitate and cardiopulmonary resuscitation)In many cases, the "expressed wishes" of the patient are documented inthese directives, and this provides a framework to guide family membersand health careprofessionals in the decision making process when the patient isincapacitated. Undocumented expressed wishes can also help guidedecisions in the absence of advanced directives, as in the Quinlan casein Missouri.
"Substituted judgment" is the concept thata family member can give consent for treatment if the patient is unable(or unwilling) to give consent himself. The key question for thedecision making surrogate is not, "What would you like to do?", butinstead, "What do you think the patient would want in this situation?".
Courts have supported family's arbitrary definitions of futility to include simple biological survival, as in the Baby Kcase (in which the courts ordered a child born with only a brain steminstead of a complete brain to be kept on a ventilator based on thereligious belief that all life must be preserved).
A more in-depth discussion of futility is available at futile medical care. In some hospitals, medical futility is referred to as "non-beneficial care."

Baby Doe Lawestablishes state protection for a disabled child's right to life,ensuring that this right is protected even over the wishes of parentsor guardians in cases where they want to withhold treatment.

Critics claim thatthis is how the State, and perhaps the Church, through its adherents inthe executive and the judiciary, interferes in order to further its ownagenda at the expense of the patient's. Ronald Reagan'sAmericans With Disabilities Act was a direct response to the Baby KCase, in an effort to prop up "Right to Life" philosophies[citation needed].
[edit] Further reading