Medical ethics: principles, history, and practical issues

From Antiquity to Modern Times

In almost all cultures, physicians have made solemn commitments regarding their medical art, their relationship to patients and to their own profession. In Europe, where a medical ethic had developed with the Hippocratic medical science based on a high level of professional awareness among physicians, the so-called Oath of Hippocrates (ca. 4th century BC) is probably the best known. It was reformulated in a contemporary manner in the Geneva Medical Oath (1948, 1968, 1983, 2017). In the European Middle Ages, medical ethics was based primarily on theological ethics and medical ethics was determined in particular by Christian charity and mercy, with scholasticism seeking to combine the aspects of Christian theology and Aristotelian philosophy to be discussed in the process.

Modern medical ethics from the 19th century onwards

The founder of today's medical ethics is the English physician Thomas Percival, who published the work Medical Ethics one year before his death in 1803 and thus also coined the term. In it, he developed the first modern code of ethics, from which the first Code of Ethics of the American Medical Association was derived when it was founded in 1847 and which was directly adopted in many passages.

After 1945

Euthanasia programs and human experimentation under National Socialism, Japanese experiments on prisoners of war, the abuse of psychiatry in the Soviet Union, certain research experiments in the United States, and other distressing experiences demonstrated that the medical profession's ethos is not sufficient to prevent criminal abuse of medical knowledge and ambition. At the Nuremberg Medical Trial (1947), a Nuremberg Code was established as the basis for conducting necessary and ethically tenable medical experiments on human beings. In 1964, the World Medical Association adopted a "Declaration on Ethical Principles for Medical Research Involving Human Subjects" (Declaration of Helsinki), which was later updated several times (most recently in 2013) and is applied in many countries.

Finally, the challenges posed by new developments in medicine from the 1970s onwards (e.g. prenatal diagnosis, cloning, etc.) led to an enormous differentiation of medical ethics. The use of resources in health care must also be discussed from an ethical point of view.

Ethics Committees

In the 1980s, ethics committees for human medical research were established in Germany at the medical faculties or at the state medical associations. When reviewing research projects, they are guided by legal regulations and the respective professional codes for physicians. They have the status of an advisory body and only become active upon application.

The German Medical Association established a Central Ethics Committee in 1995: it has published opinions on, among other things, research involving minors, the (continued) use of human body materials, stem cell research, the protection of persons incapable of giving consent, the protection of personal data in medical research and priorities in medical care.

Since 2001, Germany has had a policy advisory body in the form of the German Ethics Council to address questions of medical ethics in civil society discourse.

Medical ethics at universities

Medical ethics is a separate research and teaching subject at German universities. At present (as of June 2019), there are professorships dealing with medical ethics at 20 German universities. With the comparatively small number of dedicated professorships, medical ethics thus belongs to the group of small subjects (see also List of Small Subjects). However, it can be said that medical ethics has become more relevant at universities in recent years: since 1997, the number of locations and professorships has increased about fivefold.

Dental ethics

For dentists, there is an ethics working group within the German Society for Dental, Oral and Maxillofacial Medicine (DGZMK), as well as ethics committees established at the state dental association in some federal states. It is concerned with the development of basic ethical rules in dentistry.

In their book Principles of Biomedical Ethics, Tom Lamar Beauchamp and James F. Childress develop an ethics of principles. Central to this are four basic principles of medical ethics. The four principles are respect for the autonomy of the patient, avoidance of harm, care and justice. The starting point of principle ethics is our everyday morality. It should be included in the process of ethical reasoning and decision making. Beauchamps and Childress' ethical theory has been particularly popular in medicine because they have designed the principles in such a way that they allow room for consideration and prioritization of individual principles in the applied case. The application of these four principles is a two-step process. Basically, each principle must be interpreted in each specific case. This is called interpretation. Then it must be checked whether these principles are in conflict or in harmony in such a concrete case. If the former is the case, a balance must be struck. This process is called weighting.

Justification of middle moral principles

The ethics of principles of Beauchamp and Childress is on the one hand an ethics for application in medical contexts, on the other hand it also represents a philosophical position that differs from traditional theories. For two centuries, various ethical theories have been competing with each other (e.g. utilitarianism, Kantian ethics or contractarian ethics). So far, however, none of these ethics has been able to prevail. Because of this, and because of the need and urgency for ethics in medicine, Beauchamp and Childress decided on an approach that turned away from a comprehensive ethical theory with a supreme moral principle and focused on "middle" principles that should be compatible with different moral theories. In doing so, they originally adopted the idea of William David Ross's prima facie duty. These principles, according to Beauchamp and Childress, are supposed to be tied to our everyday moral beliefs (common morality). These are then reconstructed and brought into a coherent context in a further process of interpretation, concretization and weighting. One therefore speaks of a reconstructive or coherentist approach to reasoning. Here, Beauchamp and Childress take up John Rawls' idea of the equilibrium of consideration, but give greater prominence to everyday moral beliefs. Now our moral everyday convictions do not only represent the starting point, of this ethical theory, but it is at the same time also a kind of corrective. Thus ethical theory and moral practice are interrelated. Thus ethical theory offers orientation in practice, but then it must also prove itself there. These "middle" principles are not absolute, but rather subsidiary to general moral principles. Thus they are only valid if they do not collide with higher or equal obligations. Accordingly, the different principles must often be weighed against each other.

The four principles

1. autonomy

The principle of autonomy (also respect for autonomy) grants every person competence, freedom of choice and the right to the promotion of decision-making capacity or self-determination. It includes the requirement of informed consent before any diagnostic and therapeutic measure and the consideration of the will, wishes, goals and values of the patient.

2. harm avoidance (non-maleficence)

The principle of nonmaleficence calls for harmful interventions to be avoided (taking into account the risk-benefit ratio and individual values). This is based on the traditional medical principle "primum non nocere". At first, this seems self-evident. However, there are cases in which it is very difficult to decide what will help or rather harm the patient. This is especially the case in highly invasive therapies such as chemotherapy.

3. care (beneficence)

The principle of beneficence obliges the practitioner to act actively in a way that promotes and benefits the patient's well-being (especially life, health and quality of life). Traditional medical ethics formulates a similar principle (salus aegroti suprema lex), which, however, is superior to all others. In principled ethics, four principles are on the same level. The principle of care is often in conflict with the principle of autonomy and the principle of avoidance of harm. Here, careful consideration should be given to the benefits and harms of an intervention, taking into account the patient's wishes, goals and values.

4. justice

The principle of justice calls for a fair and appropriate distribution of health care services, taking into account resources. Equal cases should be treated equally; in the case of unequal treatment, morally relevant criteria should be specified. The principle demands a fair distribution of health care management. For example, the resources and capacities of hospitals must be distributed fairly. Every case of illness of a person that is equivalent, i.e. equal, to another case demands equal treatment. Unequal cases may be treated differently, but only if the cases have morally relevant differences. Unequal treatment is not justified based on nationality, gender, age, place of residence, religion, social status or previous behaviour in society. Even previous criminal offences or professional activities may not be taken into account in the decision. For example, a beggar is placed on an equal footing with a lawyer in terms of medical treatment, provided they have the same symptoms and equal chances of survival. The decision regarding medical treatment must be factually justified, transparent and fair.

Application example of the four principles

In the concrete example, the four principles are first applied to the case, and then a consideration is made on the basis of the developed foundation. In order to apply the principles, it is now assumed that it is possible to treat a person with advanced lung cancer with chemotherapy. Since this would be the third therapy, the patient opposes the treatment despite the chances of cure being intact. If the case is interpreted from the perspective of the first principle, the negative right of freedom of the patient applies, whose autonomy would be preserved by refusing the therapy. In the specific case, it would also have to be verified whether the patient has the mental capacity to form her own free will, so that one can speak of the patient's will. In this example, this aspect is assumed. Since chemotherapy is unlikely to harm the patient, the principle of avoidance of harm is fulfilled. The fact that side effects may occur during chemotherapy must be known to both the physicians and the patient (see Prerequisites of the Principle of Autonomy) in any therapy. The principle of care obliges the physician to act actively. While the principle of non-harm can be used as an argument for both administering and suspending further chemotherapy, in this case the principle of care commands the therapeutic action because the patient's welfare is being promoted. The principle of justice is only applied in this example insofar as the consideration of whether another patient is not denied treatment due to the limited capacities of the hospital must also play a role. Since the treatment of the patient is objectively well justified, however, further consideration is not necessary here. The interpretation of the four principles is followed by the balancing of interests. A final judgement cannot be made here on the basis of the principles, as there is no general weighting. However, with the help of the principles it was possible to reveal what the moral conflict is in the example described. Is the patient's right to self-determination or the doctors' duty of care given greater weight?