BIOETHICS IN PRACTICING MEDICINE

It is commonly argued that modern advances in medical technology, antibiotics, dialysis, transplantation, and intensive care units have created the bioethical dilemmas that confront physicians in the 21st century. Concerns about ethical issues are as old as the practice of medicine itself, however. The Hippocratic Oath, composed sometime around 400 bc , attests to the need of ancient Greek physicians for advice on how to address the many bioethical dilemmas that they confronted. The Oath addresses issues of confidentiality, abortion, euthanasia, sexual relations between physician and patient, divided loyalties, and, at least implicitly, charity care and executions. Other Hippocratic works address issues such as terminating treatments to dying patients and telling the truth. Whether we agree with the advice dispensed or not, the important point is that many bioethical issues are not created by technology but are inherent in medical practice. Technology may make these issues more common and may change the context in which they arise, but there are underlying bioethical issues that seem timeless.

Many physicians have been educated that four main principles can be invoked to address bioethical dilemmas: autonomy, nonmaleficence, beneficence, and justice. Autonomy is the idea that people should have the right and freedom to choose, pursue, and revise their own life plans. Nonmaleficence is the idea that people should not be harmed or injured knowingly; this principle is encapsulated in the frequently repeated phrase that a physician has an obligation to "first do no harm"- primum non nocere . This phrase is not found either in the Hippocratic Oath or in other Hippocratic writing; the only related, but not identical, Hippocratic phrase is "at least, do not harm." Although nonmaleficence is about avoiding harm, beneficence is about the positive actions that the physician should undertake to promote the well-being of his or her patients. In clinical practice, this obligation usually arises from the implicit and explicit commitments and promises surrounding the physician-patient relationship. Finally, there is the principle of justice as the fair distribution of benefits and burdens.

Although helpful in providing an initial framework, these principles have limited value. They are broad and open to diverse and conflicting interpretations. In addition, as is clear with the principle of justice, they frequently are underdeveloped. In any difficult case, the principles are likely to conflict. Conflicting ethical principles are precisely why there are bioethical dilemmas. The principles themselves do not offer guidance on how they should be balanced or specified to resolve the dilemma. These principles are focused on the individual physician-patient context; they are not particularly helpful when the bioethical issues are institutional and systemic, such as setting priorities or policies. Finally, these four principles are not comprehensive. There are other fundamental ethical principles and values, such as communal solidarity, duties to future generations, trust, and professional integrity, that are important in bioethics but not encapsulated except by deformation in these four principles.

There is no formula or small set of ethical principles that mechanically or magically gives answers to bioethical dilemmas. Instead, medical practitioners should follow an orderly analytic process. First, practitioners need to obtain the facts relevant to the situation. Second they must delineate the basic bioethical issue. Third, it is important to identify all the crucial principles and values that relate to the case and how they might conflict. Fourth, because many ethical dilemmas have been analyzed previously and subjected frequently to empirical study, practitioners should examine the relevant literature, whether it is commentaries or studies in medical journals, legal cases, or books. With these analyses, the particular dilemma should be reexamined; this process might lead to reformulating the issue and identifying new values or new understandings of existing values. Fifth, with this information, it is important to distinguish clearly unethical practices from a range of ethically permissible actions. Finally, it is important not only to come to some resolution of the case, but also to state clearly the reasons behind the decisions; that is, the interpretation of the principles used and how values were balanced. Although unanimity and consensus may be desirable ideals, reasonable people frequently disagree about how to resolve ethical dilemmas without being unethical or malevolent.

A multitude of bioethical dilemmas arise in medical practice, including issues of genetics, reproductive choices, and termination of care. In clinical practice, the most common issues revolve around informed consent, terminating life-sustaining treatments, euthanasia and physician-assisted suicide, and conflicts of interest.