A. Definition of the Term
Ethics is the
branch of philosophy which deals with moral aspects of human behavior.
Some differentiate between ethics and morals. Ethics deals with the
theories and principles of values and the basic perceptions and justifications
of values, whereas morals includes the
customs, and normative behavior of people or societies. Nevertheless, these
terms are often used interchangeably, their meanings now overlap and they are
becoming virtually synonymous.
Medical ethics in the narrow historical
sense refers to a group of guidelines, such as the Oath of Hippocrates,
generally written by physicians, about the physician’s ideal relationship to
his peers and to his patients. Medical ethics in the modern sense refers to the
application of general and fundamental ethical principles to clinical practice
situations, including medical research. Individuals from various disciplines
may author these principles. In recent years, the term has been modified to biomedical
ethics which includes ethical principles relating to all branches of knowledge
about life and health. Thus, fields not directly related to the practice of
medicine are included, such as nursing, pharmacy, genetics, social work,
psychology, physiotherapy, occupational therapy, speech therapy, and the like.
In addition, bioethics addresses issues of medical administration, medical
economics, industrial medicine, epidemiology, legal medicine, treatment of
animals, as well as environmental issues.
discusses general ethical principles, developments of basic principles of
medical ethics, and ethics teaching in medical schools. The practical
applications of these principles in specific medical situations are found in
different sections of the medical halachic encyclopedia.
beginning of human history, concern for medical ethics has been expressed in
the form of laws, decrees, assumptions and “oaths” prepared for or by
physicians. Among the oldest of these are the Code of Hammurabi in Babylonia (approximately 1750 BCE), Egyptian papyri,
Indian and Chinese writings, and early Greek writers, most notably Hippocrates
(lived between 460 and 377 BCE).
Early medical ethical codes were written by individuals or by small
groups of people, usually physicians. The Oath of Hippocrates is considered
historically to be the first such code written in an organized and logical way
which describes the proper relationships between physician and patient. During
the Middle Ages, other medical codes were written. In recent times, Thomas
Precival’s writings, disseminated in 1803, represent one of the first ethical
codes in the United States
and the Western world.
Beginning in the second half of the nineteenth century medical organizations
began writing codes of medical ethics. The first ethics code of the American
Medical Association (AMA) was published in 1847. This was the
first ethical code of a professional organization which outlined the rights of
patients and caregivers. Over the years many revisions and additions to this
original code have been made. The latest edition of the AMA Code of Medical
Ethics (1997) contains four parts, which include general principles, opinions
on specific issues and special reports. The AMA established the Council on
Ethical and Judicial Affairs to advise it on legal and ethical issues and to
prepare position papers on these issues for the AMA. The British Medical
Association published its first code of Medical Conduct of Physicians in 1858.
The code has subsequently undergone numerous changes. The World
Health Organization (WHO) issued the Declaration of Geneva in 1948. This is the
first worldwide medical ethical code and is modeled after the Oath of
Hippocrates. Many other medical organizations throughout the world, including
those in Israel,
have issued medical ethical codes.
Modern medical ethics as a separate field began to develop in the 1950’s.
One of the major innovations of modern Western medical ethics involves the
physician-patient relationship with the dramatic change from paternalism to
autonomy and its resultant requirement for informing the patient, obtaining
informed consent, and relating to the patient as an active partner in
General Ethical Principles and Theories
The study of ethical theories provides a logical framework for the
understanding of the ethical dimensions of human conduct, helps one to
recognize ethical dilemmas and provides tools for their resolution. Ethics
examines and measures human conduct. Accepted practices of human conduct in a
given country are termed normative behavior. Ethical standards are used to
evaluate and ensure the appropriateness and desirability of such practices.
A value usually denotes the good, the beneficial in ethics, the truth in
cognition, and the holy in religion. A value is not determined objectively. It
is not a scientific term and cannot be scientifically defined. Therefore,
science is neutral with respect to most bioethical values. A value represents a
subjective assessment and may be measured by what a person is willing to
sacrifice for it and not by what it gives to him.
Ethical dilemmas are created only in relation to human beings, within the
framework of relations between one human being and another. They arise when two
or more alternative actions, each of which is inherently good, yield
conflicting outcomes. Or an action that benefits one person may cause harm to
another. In such situations, one must find the ethical justification for each
course of action and have a system of prioritization to select the most
appropriate one. Ethics asks what should be done, not what one ordinarily does
and not what one could do.
The two central questions in ethical theories are:
What is the good for which we strive or should strive, and what is the
evil that we would like to or must avoid?
What is the proper or desired course of action, and what is the
inappropriate or forbidden course of action?
people believe the two questions are interrelated and debate which comes first
and which is the corollary. Others totally separate the two questions.
Sometimes the dilemma is factual and not one of values. In such cases,
debates and discussions may result from imprecise knowledge about the facts
related to the dilemma either due to lack of actual information or lack of
clarity or understanding of positions and views about the issues. Often mere
clarification of the facts may resolve the ethical question. Good ethics starts
with the correct facts. A decision is inherently unethical if it is based on
erroneous or incomplete data. Therefore, the first step in adjucating a
concrete medical ethical issue is to gather the pertinent facts. Proper
clarification of the facts often avoids futile ethical debates. Sometimes
debates result from differences in the fundamental positions of the people
involved. Even in such cases, a clear and precise presentation of the various
positions may achieve mutual respect, precision of ethical focus, and sometimes
even resolution of the ethical dilemma, even if a consensus is not reached.
Ethical dilemmas would not exist if ethical principles were like parallel
lines which never intersect. However, in reality values do not function in that
way. Rather they go in different directions and involve situations where values
conflict with each other. Then, one must choose between good and bad values or
between values of greater or lesser utility. Sometimes, resolution of an
ethical problem is easy with a single, unanimous agreed upon course of action.
At other times, the resolution is a compromise between opposing interests, with
no one totally satisfied.
Theoretically, ethics should decide between good and bad, between proper
and improper, between correct and incorrect. But the proverb says: A wise
person is not the one who knows how to choose good from bad, but he who chooses
the lesser of two evils.
acts can be evaluated on four planes:
the desire, intent or motivation
the ethical principle, theory or value
Various ethical teachings emphasize one or more of these planes, and some
utilize all four. At times one needs to consider specific circumstances, which
may be temporary or changing, or one needs to find a middle path between
opposing and contradictory values.
Ethics differs from precise science in several ways:
One cannot readily subject ethical questions to controlled
experimentation and study and one cannot separate purely ethical considerations
from personal-subjective influences which are affected also by cultural and historical
backgrounds. Since ethical decisions are influenced by historical,
philosophical, socio-cultural and religious attitudes, each with strong
subjective components, there are few universal objective truths. The most
widely used terms in ethics are “good or bad,” “proper or improper,” and
“correct or incorrect.” In contrast, in the physical and natural sciences, we
arrive at specific conclusions based on objective observations or experiments
with minimal human biases. Therefore, the terms used in science are “true and
Science arrives at conclusions whereas the ethics provides decisions or
recommendations. A conclusion is the obligatory acceptance of the facts whereas
a decision or recommendation is a voluntary choice among various options. Furthermore, a
scientific conclusion is based on the past, i.e. previous studies which lead to
present conclusions. Ethics, on the other hand, is future oriented, that is to
say a present choice is based on a future desire, intent or consequence. Thus
the word “cause” is a scientific term which explains a current situation based
on earlier data whereas the words “reason” and “argument” are value terms which
attempt to justify current action based on desires or motives.8
If an error is discovered in scientific knowledge, the scientist can
correct it by explaining the facts differently without requiring him to change
his personal conduct. By contrast, if an error is discovered in a value
judgement or ethical conduct, “repentance” is required with a change in the
person’s behavior.8 In science only success of the
effort is considered significant whereas in ethics the effort itself in trying
to resolve the dilemma is considered worthwhile. Many scholars in ethics and
religion believe that the attainment of perfection should not be the ultimate
goal. Rather, the goal should be the effort to gain perfection since its actual
attainment is all but an impossibility for a human being. This is also true
from a religious point of view – it is erroneous to believe that a person is
obligated to recognize the truth; rather, one must seek the truth since
absolute truth is only with God.
Ethics also differs from laws and religion in that
the latter two provide definitive and absolute rulings. By contrast, ethics in
general does not decide absolutely, but rather focuses and clarifies questions
and issues and presents options and alternatives for dilemma resolution.
There have always existed various ethical schools of thought with
significant differences between them. They differ in the principal
justifications and validity of the various ethical theories as well as in the
terminologies, the specific principles and rules, the relative relationship
between them and in their practical application.
One of the basic ethical questions is the source and validity of values.
Ancient Greek philosophers debated this issue. Plato and the Stoics argued that
the validity of moral cognition is absolute and objective and that universal
ethical laws and principles apply to all people in all places and at all times.
By contrast, the sophist and skeptic philosophers argued that one cannot prove
or justify a universal ethical law or value, and they believed that ethical
principles are relative, and dependent on the place, the time, and the
circumstances. An intermediate view was that of Pythagoras and his followers
who said that certain values and norms exist for certain populations but may
vary in different cultures and be influenced by external circumstances.
These basic differences of opinion remain even in modern times. Some
philosophers view most or even all values merely as subjective recommendations
which differ from society to society and from era to era and, according to the
circumstances, even from person to person. This view is based on the observation
that various actions are perceived differently by various societies. According
to this view, ethical values are not innate but must be acquired and hence are
influenced by forces which determine various types of behavior. Some
philosophers define the source of ethics to be one’s emotions, that is to say
an action is ethical if it makes one feel content and good, and bad if it
evokes a feeling of disgust and revulsion. Or an action is ethical if it
produces joy, and bad if it leads to sadness (this view is espoused by David
Hume, Spinoza and Stermack). According to these views, emotions and social
habits are the sources for the validity of ethics.
By contrast, some philosophers recognize absolute and universal values
which change neither according to external needs and circumstances, nor from
society to society, or from era to era. The source of these values is either
factual-empiric, intuitive, or metaphysical-religious. This view is based on
the thesis that certain values and conduct are universally accepted as ethical
or unethical in all societies and in all eras. This view also asserts that
relativism is unfounded, unjust and empties ethics of any real content since it
changes with differing temporal circumstances and conditions (the main proponent
of this view is Immanuel Kant).
Two basic theories exist today in the fundamental approach to
The utilitarian (or consequential or teleologic) theory which measures
the value of an action by its consequences. An appropriate or good action is
one which brings the most beneficial results for the most people. This view in
its classic sense opines that the goal of ethics is to bring the most good to
the most people so that ethical principles are used as vehicles to attain the
highest or ultimate good. Ethics thus has a specific goal and each action is to
achieve that goal.
There is obviously great variability in deciding what is the ultimate
good towards which attainment one is to strive. Some view a specific individual
goal as the ultimate good (=a monistic view, the main proponents of this view
are Epicurus, Spinoza and Nietzsche), be it happiness (the main proponents of
this view are Aristotle, Socrates and the Greek Stoics, and in modern times
Stuart Mill), self-fulfillment (proposed by Hegel and Bradley) or pleasure
(=hedonism). Thus, the individual’s own opinion is decisive and any action
which gives that person benefit is by definition ethical and good. Others
believe that the good should be a general one for society and not just for the
individual. Thus, an action is ethical if it brings great pleasure to the
largest possible number of people (the main proponents of this view are Hume
and Bentham). Some view the attainment of physical pleasure to be the ultimate
good whereas others consider mental pleasure and benefit to be the crowning
By contrast, some philosophers argue that there is no single purpose
which is the sole good; rather several goals should be sought (=a pluralistic
view, espoused by Mohr). Examples of good goals are love, health, happiness,
friendship, and beauty, each one of which is an ultimate good in itself.
Therefore, ethical acts need to be assessed on the basis of the greatest
progress that they produce towards the conglomerate of these values and not
just for pleasure and avoidance of suffering.
A third utilitarian view is that the best goal is to promote individual
preferences towards the fulfillment of personal desires and ambitions, that is
to say the main goal is the realization of what the individual or the group
view as good for them, within specific conditions and time frameworks.
Utilitarianism has been strongly criticized for many reasons:
It is based on the ability to measure the good consequences and compare
between various goods. How can one, however, measure individual ethical ‘units’
of goods such as pleasure, happiness, love, etc.?
In many concrete situations, it is very difficult to weigh the expected
benefit if varying and conflicting actions are taking place.
It is impossible to prove with certainty that a single value is the
ultimate good for which one should strive. The choice of pleasure as the
ultimate good is open to debate just as is the choice of any other simple
Utilitarianism lacks ethical consistency in decision-making because it
changes with different expected outcomes.
It can easily lead to unjust social actions in that actions that benefit
the majority of people may create serious harm to the remaining minority.
In a utilitarian system, who decides what should be the best outcome and
how does one decide? The sub-group which views individual preferences as the
ultimate good resolves this question but produces a much more difficult issue
in that often other peoples’ desires and preferences are ignored. Thus,
utilitarianism can undermine the whole ethical foundation of universal
The main theoretical objection to utilitarianism is its premise that
ethical acts themselves have no intrinsic value because their ethical validity
is based on their outcomes or consequences. Thus the goal justifies the means.
Hence, some acts can be ethically wrong but are justified because their outcome
produces the desired benefit as defined above.
Deontological theories of
ethics state that an act is considered ethically proper and good if it fulfills
the basic requirements of ethical principles and values of intrinsic validity,
without regard to the expected or anticipated consequences. The main proponent
of the deontological theory of ethics in its extreme form is Immanuel Kant
According to his theory there exist ethical values that dictate actions
categorically without compromise. The source of ethics is logical, universal,
and unchanging – irrespective of time or place. The ultimate good is for decisions
to be made based on one’s intent to act ethically, and not on the result or
outcome of that act. Only good intentions are good, without reservation. Kant’s
thesis is that one must act ethically because of the autonomy of one’s will and
not because of pressure, inclination or external forces of any kind
(=heteronomy). The philosophic basis of this theory of ethics is that the
ethical value of an act flows from an obligation, and the latter is the
fulfillment of ones autonomous will established by the laws of understanding
and wisdom. According to Kant, ethical behavior is required of all people of
understanding. It is not learned by experience but is established a priori
by that understanding. Therefore, ethical law is objective and absolute and
nothing can restrict it or attach conditions to it. One of Kant’s fundamental
rules is the “general formula” whereby a person must always act in a way that
everyone else should act similarly.
The deontological theory of ethics has also been strongly criticized:
Pragmatically, it is difficult to determine who decides on absolute
values and how they are implemented.
The extreme view of this theory that completely ignores the goals and
consequences of actions, cannot be applied practically, because the absolutism often
leads to impossible situations in daily living and may produce great harm.
The deontological theory provides no mechanism to decide between two or
more universal-absolute values when they are in conflict with each other.
Situations frequently arise requiring a choice between two “absolute” values.
There is no way, in Kant’s approach, to apply his general principles to such
A number of neo-Kantian theories developed trying
to resolve the above difficulties.
Some writers combine deontology with utilitarianism and require
one to pay attention to absolute and universal values which every decent human
being should follow (= prima facie obligation). If, however, they
conflict with equal or even stronger ethical imperatives in certain situations,
the latter may have to be adopted and the universal values set aside.
Another attempt at resolving the difficulties with the Kantian approach
is to emphasize the principles of honesty, equality, and social justice. In
this view, ethical principles are those which all people would agree should
they be evaluated freely and independently of the actual social situation, were
they to examine them from an “original” position. In their view,
social justice is the highest ethical value and different characteristics of
individual people are ignored.
Because every well-defined ethical theory has its problems, either in
relation to its characteristics or in relation to its practical application,
some writers speak of relativistic or situational ethics which are determined
by the situation, the time, the place, the culture, etc. Thus, according to
this approach there are no universal principles applicable at all times, in all
places and for all situations. Rather, each situation is decided according to
the appropriate culture, time, place, and circumstances. This view can
undermine the basis of ethics and morality and leads to ethical anarchy. It is
not helpful in resolving ethical questions in a consistent manner.
In recent years, several fundamental ethical principles have been
formulated and widely adopted as the basis for ethical discussion in medicine:
Autonomy is defined as a fundamental principle based on the worldview
that every person has intrinsic value. One may not restrict nor negate the free
wishes of an individual with respect to his own body. One must facilitate any
desired action acceptable to a person’s own judgement and in accordance with
his own choice. The granting of autonomy requires that we recognize and accept
the free choice of each person even if that choice seems inappropriate or
foolish or even life-endangering.
A precondition for autonomy is complete freedom of the individual from
outside control or pressure. Any action that derives from external control
which interferes with one’s expression of autonomy is termed heteronomy. By
definition proper, full autonomy cannot be exercised by the very young, the
mentally retarded or the psychotic. Also autonomy is not to be respected if
such a choice is likely to harm others.
Many ethicists view autonomy as the most important ethical principle
which supercedes all others. In recent
years, the tendency is to decide more and more medical ethical and legal
dilemmas according to this principle. Other ethicists view autonomy as only one
of several important ethical principles. This view is
based on the recognition that one should not totally abandon other ethical
principles regarding the physician’s obligations toward his patients. Some writers
even consider it “tyrannical” to view autonomy as the most important value with
dominance over all others, and that such
a practice might lead to public ethical anarchy. One should
also recognize that the Western world’s espousal of autonomy is not universally
accepted in all societies and cultures, and certainly not in Judaism.
Therefore, some writers state that unrestricted autonomy is culturally
Autonomy is not only the privilege of the patient. It is universally
agreed that the physician’s autonomy, too, must be respected. A physician may
refuse a patient’s request for a therapy that has no scientific or rational
basis, especially if it may be harmful to the patient. Also, a physician may
refuse to implement a patient’s decision for a certain treatment if it
conflicts with the physician’s conscience, for whatever reason. In such
situations, the physician has the right not to treat the patient and to
transfer such care to another physician. A difficult question relates to very
expensive treatment requested by a terminally ill, incurably sick patient which
could only minimally extend the patient’s life. Some writers justify the
physician’s autonomy in deciding against the patient’s autonomy whereas others
consider such action to be unjust.
Non-maleficence (=primum non nocere) is defined as the obligation
not to harm others and to remove and prevent potential harm. Thus, one must
not only prevent intentional harm but must also be appropriately cautious not
to cause harm. Health care workers must be properly trained so that they not
inflict harm because of lack of knowledge or lack of appropriate skills.
This concept of non-maleficence is applied to the relationship between
physician and patient based upon the phrase that “above all do no harm.” Some
writers state that nowadays non-maleficence should be re-defined to strive not
to do harm, by balancing the benefit against the harm of any specific action.
However, this ethical principle of not doing harm should not be absolute and
cannot be applied fully in all diagnostic and therapeutic interventions. The cause for
this change in the definition of non-maleficence relates to the major changes
in the practice of medicine today as compared to that practiced in antiquity.
Beneficence is defined as the moral obligation to do good for others, and
to help them in an active way. Ethically, it is not enough to avoid doing harm
but one must actively do good to others. But, obviously there are limits to the
requirement that one act to help others at all times. These vary with the
degree of need, the ease and ability with which the help can be rendered, and
the nature of the relationship between the individual needing help and the one
able to provide it.
Justice is the granting and fulfillment of legitimate rights of others,
and injustice is their denial. Justice requires the division of rights and
assets in an equitable and appropriate manner, but no less so the fair
distribution of duties and burdens. In the simplistic sense, justice means
equality. However, in daily life, many variables cause unequal division of
obligations and rights. Therefore, several ethical theories and techniques have
been developed for distributive justice, taking into consideration needs,
rights, contributions to society, and other factors.
Different theories of justice place greater priority on different
factors: Marxism emphasizes economic needs, while liberalism emphasizes social
needs. The differences in views and emphases make it difficult to attain ideal
justice, since equality in one aspect may bring inequality in another and, hence,
Individual rights became a cornerstone in political, legal and social
thinking in the nineteenth century. Some believe that people have absolute
moral rights unrelated to changing social conditions. These include “natural”
universal rights such as the right to life, liberty and privacy. Others believe
that rights flow from societal consensus, customs and laws and therefore are
relative and may change according to the circumstances.
D. Modern Medical Ethics
Modern medical ethics is based on concepts derived
from various disciplines, including the biomedical sciences, the behavioral
sciences, philosophy, religion and law. Modern medical ethics is essentially a
form of ‘applied ethics,’ which seeks to clarify ethical questions that
characterize the practice of medicine and to justify and weigh the various
practical options and considerations. Thus medical ethics is the application of
general ethical principles to ethical issues. The application of such an ethic
is not specific to medicine but also relates to economy, law, journalism, and
In the past, only a few individuals, mostly physicians, devoted
themselves to medical ethics. Beginning in the second half of the twentieth
century, the field underwent explosive expansion and experts from numerous
disciplines entered the field.
The rapid advances in medical diagnosis and treatment and the
introduction of new technologies have produced numerous new ethical dilemmas, resulting in
the maturation of medical ethics as a specialty in its own right. Research
institutes of medical ethics have been established. Medical ethics is now part
of the curriculum in schools of the health professions at all levels. The
medical ethics literature has proliferated, with numerous books and journals
devoted entirely to the subject. Nearly all medical periodicals devote
considerable space to ethical topics. The general
public is also vitally interested in this subject, and public lectures,
newspaper articles, legal discussions and legislation on medical ethical issues
In the United States,
the “medical ethicist” has emerged as a new professional. These individuals
generally have specialized in one or more of the fields of philosophy, ethics,
law, religion and medicine, and serve as advisors in hospitals to physicians,
patients and their families. They attempt to resolve difficult ethical
questions posed to them by the medical team or by patients and their families.
In one American study, most of the medical staff found ethical consultation and
advice to be valuable but only half of patients or families found it to be
A number of reasons are responsible for the enormous recent interest in
Significant technological and scientific advances and changes in clinical
medicine and research have produced totally new ethical dilemmas and
exacerbated old ones.
The change in philosophy from paternalism to autonomy in the
physician-patient relationship has removed from the physician the monopoly on
The involvement of additional caregivers (various medical specialists, a
variety of health professionals, students, administrators and investigators),
each with their own cultural and social value systems, have increased and
sharpened ethical debates and discussions.
The involvement of society at large (through the mass communication
media, courts, legislators) has created the necessity to redefine the societal
parameters of the physician-patient and physician-societal relationship.
Broad social changes throughout the world have damaged the image of the
unique nobility of the physician. This change has been enhanced by the
commercialization of medical services and the greater sense of consumer
criticism. Moreover, in recent years physicians have come to view medicine more
in terms of their careers, honor, self-fulfillment and income. There is a
call nowadays to return to the historic principles of the medical profession,
which differs from most other professions. Medicine should be viewed as service
to the sick and the needy, with humility, honesty, empathy, intellectual
integrity, and effacement of self-interest.
A number of significant socio-ethical changes have
occurred in the portrayal by society of medical practice and the medical
profession. In the past, it was thought that all illnesses had a limited number
of causes with only minor variations between people. Thus, a holistic view of
people was prevalent. The limited armamentarium of diagnostic testing and
therapeutic interventions enhanced close communication between the physician
and the patient because a detailed history and physical examination were
virtually the physician’s only diagnostic tools. Scientific knowledge of
medicine was limited, and the art of medicine was emphasized. By contrast,
modern medicine has traced disease causation to a multitude of processes in
individual organs, tissues or even cells. The diagnostic and therapeutic
approaches focus primarily on the illness and less so on the patient, changing
the physician-patient relationship dramatically. Since most diagnostic tests
and many therapeutic interventions are performed in specialized laboratories
and treatment centers, there is far less need for communication and interaction
between the patient and the physician. Science and technology are glorified at
the expense of humanism, and this is reflected in medical education. A 1984
study reported that only 3% of American medical students had majored in
humanistic subjects in their premedical education. Classically,
medicine had been identified with the humanities. Nowadays, young physicians
choose careers in narrow subspecialty areas with emphasis on clinical or basic
research. This approach has led to a reduction of empathy for the sick person
and loss of the individual human concern.
This trend began to reverse itself in the 1980’s and 1990’s. Public
pressure and the profound realization of the purposes of medicine and its roles
resulted in attempts to balance the technological and scientific advances with
the humanistic and ethical approach to medical practice. Medical ethics
attempts to help resolve some of these issues.
Economic issues engendered as a result of the high cost of modern medical
care have created new dilemmas which require resolution, both on an individual
and on a societal level. Economic pressures have added a new dimension to the
physician-patient relationship. The physician’s responsibility to his patient
often conflicts with those to his employer, the insurance company or the
The physician must skillfully and ethically balance these ethical conflicts.
However, in practice, the influence of medical ethics in the United States
on the formation of public policy or even the education of scientists and
physicians has not been very great. Some critics regard modern medical ethical
discussions as excessively academic and theoretical and insufficiently
forceful. Furthermore, governmental, political and economic considerations
often influence the appointment and financing of medical ethics task forces or
commissions, leading to biased results. If ethics is
to have a major impact on society there needs to be greater motivation on the
part of society and intensive education towards appropriate ethical conduct and
concern for one’s fellow human being.
Medicine is not an exact science. It deals with people and not objects.
Therefore, its scientific and humanistic components must be combined. Better
and more knowledge per se does not necessarily lead to better medical
care since the subjective feelings of the patient, which are based on personal,
social, cultural, and economic value systems, must also be considered.
Therefore, clinical and research medicine need to combine technical knowledge
and advances with human feelings, ethics and social justice. Only optimal
synthesis of these two elements can educate ideal physicians who can “serve
mankind with respect, honor and dignity.” Many areas in
medicine do not involve pure science but are built on interpersonal
relationships, feelings, morality and appropriate psychosocial conditions. If
medicine’s function was only to cure illness, it would be a pure science
without any relationship to morality or justice. However, since medicine’s goal
is to cure people of their illnesses it has major humanistic and ethical
The basic concept of medial ethics is that the physician has a moral (and
at times legal) obligation to act for the patient’s good, using the most
up-to-date information. The question is how to establish that “good,” who
defines it, and what are the components thereof.
One of the most important areas of discussion in ethics is the
doctor-patient relationship which is portrayed in one of several ways:
Paternalism is an approach in which the physician chooses the
treatment for the patient because the physician’s professional knowledge,
experience and objectivity best qualify him to judge the ideal treatment for
the patient. This attitude assumes that the physician and the patient have a
common interest but that the doctor is better equipped for the necessary
decision-making with minimal or no patient involvement.
A number of significant criticisms of paternalism are as follows:
It impinges on the basic rights of the patient to decide for himself what
should be done with his body.
Many decisions are not purely medical but involve personal and cultural
aspects in which the physician has no particular expertise. Such decisions
require the patient’s input.
Many diagnostic and therapeutic decisions involve ethics, secular law or
Jewish law. For example, the decision as to whether or not to abort a fetus
with Down’s syndrome is not a medical one, but an ethical, legal and religious
one. Similarly, the decision whether or not to attempt to resuscitate a
terminally ill patient is an ethical rather than a purely medical one.
Autonomy means that only the patient
knows what is best for him and only he has the right to decide. In order to do
so he needs to receive from the physician all the appropriate information about
his condition to permit him to make an informed decision. The physician’s
values, and even less his professional knowledge and experience, play no role
in the final decision. Traditionally, the physician’s role was viewed as giving
“orders” to nurses and to patients. In the atmosphere of autonomy, physicians
must use a different language such as advise, recommendation, position, etc.
The main criticism of pure autonomy is the relegation of the physician to
the role of a technical consultant, with little influence on the patient’s
decision, which is often based on a lack of full understanding of his
condition. Such a decision may cause unnecessary and avoidable harm to the
A compromise or middle position between paternalism and autonomy is one
in which the physician provides the patient with the relevant information, the
physician and patient discuss the medical and ethical issues and then arrive at
a joint decision. This approach preserves the patient’s autonomy on the one
hand, and the physician’s obligation to advise the patient about the best
decision, on the other hand. This is considered to be the best system,
permitting responsible decisions according to the relevant individual
circumstances while preserving the obligations and rights of both patient and
The development of medical ethics in general and the physician-patient
relationship in particular can be viewed from three perspectives:
The Hippocratic view, which is based on a paternalistic physician-patient
relationship, and the basic ethical principle to prevent or minimize harm to
the patient (primum non nocere), and on professionalism between
The Jewish view, which is based on Jewish ethical principles (see the
next article in this book).
The modern view, which is based primarily on autonomy, the four ethical
principles, the multidisciplinary approach, the discussion and resolution of
every medical ethical problem, the use of guidelines and the view that medical
ethics is a specialty in its own right.
Paternalism has largely given way in favor of
autonomy throughout most of the Western world beginning in the 1950’s in the United States.
There is currently a renewed questioning of whether the pendulum has not swung
too far in favor of untrammeled autonomy and individualism. Various suggestions
have been put forward to create joint frameworks for the physician and patient
while establishing criteria for joint decision making, sharing of
responsibilities, mutual respect and mutual trust.
Much of the literature in modern medical ethics has emerged from the
English-speaking countries. These views and conclusions do not always reflect
the views in other Western countries and even less so Eastern European cultures
and Asian and African countries. These differences are to be expected when one
considers the socio-cultural differences between the various societies.
Generally, scientific progress in technology and in knowledge precedes
discussions and debates about the ethical, religious and legal aspects of that
progress. The recent extraordinarily rapid pace of advances in knowledge, science
and technology have made it even more difficult for the ethical, legal and
religious analysis of these issues to keep pace with the scientific advances.
There is a need now to change this approach so that ethical, religious, legal
and social implications of innovative scientific and technological measures
will be anticipated and acted upon in advance rather than post factum.
Modern medical ethics involves a wide range of topics which produce
ethical dilemmas in the conduct of physicians, other health professionals,
patients, families and society in general.
may be divides into general biomedical ethics which deals with fundamental
principles, societal issues and policy determination, and clinical ethics which
deals with the application of practical medical ethical principles in the
day-to-day care of patients.
The identification and characterization of a medical ethical dilemma is
not always obvious. On one general medical ward in a university hospital, while
one of every six patients posed an easily identifiable ethical problem many
ethical problems were under- identified by the medical staff.
The goals of medical ethics include the analysis of
the relative merits of alternative actions in medical ethical dilemmas.
Definite and absolute decisions are not always attainable or implementable.
Therefore, medical ethics is satisfied with decisions defining the relationship
between what is desirable and what is practical or in the choice of the lesser
of two evils. Medical ethics is generally pluralistic and multidisciplinary in
its approach. Its main function is to identify and characterize the component
elements of a given medical situation and to provide an analytic process for
assessing and applying the relevant values and principles of ethics. In
general, modern medical ethics does not see its function as providing
definitive ethical directives in every case. In this respect, ethics differs
from law or Jewish halacha. The latter establish specific guidelines, whereas
ethics provides pluralistic approaches and clarification and precision of
understanding of the ethical aspects of medical questions.
With respect to the relationship between ethics and the law – law by its
very nature in contrast to ethics, demands that it be followed precisely.
Ethics at times may conflict with the law. Many situations in medicine are not
“covered” by the law and their resolution is decided solely on ethical grounds.
The place of legislation in regard to medical
ethics is debated. Some writers would like to see major involvement of the law
in medical ethical issues and thereby to set ethical norms for society. This
view assumes that the legal system is capable of coping with the varied ethical
dilemmas created by the rapid advances in medicine. By contrast, others argue
that legislators and judges should be involved minimally only as a last resort
in ethical conflicts. The legislative process is by its very nature
conservative and slow-moving and therefore ill-suited to deal with the dynamic
changes occurring in medicine and the dilemmas thereby engendered.
A common alternative in a pluralistic democratic
society is the dealing with medical ethical issues by multidisciplinary ethics
committees, which analyze issues and recommend policy or guide- lines. There is
also considerable utility in the creation of national non-political commissions
to study new issues in medical ethics and to recommend policies and procedures
and, if necessary, legislation.
E. Teaching Medical Ethics
Because of the need in modern medicine to be knowledgeable in medical
ethics and because medical students are exposed to medical ethical issues
throughout their medical studies, it has become
necessary to teach medical ethics formally in schools of the health
The teaching of medical ethics has advanced greatly in recent years.
Nearly every medical and nursing school in the Western world now offers courses
of instruction in medical ethics.
Such teaching may take place in both the preclinical and clinical years,
during postgraduate training and as part of continuing medical education. There
are valid reasons to continue the study of medical ethics throughout the
careers of physicians and other health professionals.
The goals of education in medical ethics are:
To enhance the sensitivities of the student to medical ethical dilemmas.
To provide the student with the specific knowledge to be able to identify
and characterize medical ethical dilemmas.
To acquaint the student with terminology, views, values, and relevant
basic principles in philosophy, religion, law and sociology.
To provide the student with the intellectual tools and fundamental
thought processes to analyze and resolve ethical problems.
To present the student with the approaches of philosophy, law, culture
and religion in the resolution of medical ethical dilemmas.
To enhance the student’s ability to examine and analyze
unresolved ethical issues logically.
To instill in the student the principles of respect for individuals with
different points of view, the empathy and compassion toward
patients, and to emphasize the centrality of the patient rather than the
illness, and the importance of human values.
To educate medical specialists and experts in medical ethics.
There are many obstacles to the teaching of medical ethics. These include
Pressures of other medical studies and duties and the lack
of time for medical ethical instruction.
Lack of interest in the subject.
Lack of support from departmental chairmen and medical
Logistical problems of adequate numbers and types of trained
staff available for medical ethical teaching.
ethics teaching can be implemented in several ways:
Frontal teaching about ethical principles and issues. Common medical
ethical situations may be illustrated and discussed. The material presented
should include basic ethical principles, methods for decision making and
resolution of medical ethical dilemmas and the application of ethical
principles to clinical situations. One approach
advocates supplementing teaching of medical ethics by the addition of studies
of the humanities. Such an
approach could broaden the horizons of the physicians beyond science and
Theoretical discussions of ethical aspects during seminars of
clinical situations. Various teaching aids such as films, videos. and computer
are widely available.
Multidisciplinary “ethics rounds” at the patient’s bedside with
discussion of the ethical issues.
In every kind of teaching, a multi-disciplinary approach
is to be preferred. It is
essential to integrate the teaching of medical ethics into all facets of
medical practice and not confine it to a few theoretical lectures squeezed into
the busy schedule of medical students.
1. A variety of books are devoted to
medical ethics. These include:*
Abrams N. & Buckner M.D. (eds):
Medical Ethics, Cambridge:
MIT Press, 1983
Beachump T.L. & Walters L. (eds):
Contemporary Issues in Bioethics, 2nd ed, Belmont:
Beachump T.L. & Childress J.F.:
Principles of Biomedical Ethics, 4th ed, New
York: Oxford University Press, 1994
Brody H.: Ethical Decisions in
Medicine, 2nd ed, Boston:
Little, Brown & Com, 1981
Campbell A.V.: Moral Dilemmas
in Medicine, Edinburgh:
Churchill Livingstone, 1972
Culver C.M. & Gert B.: Philosophy
in Medicine, New York: Oxford University
Duncan A.S., et. al. (eds):
Dictionary of Medical Ethics, New
York: Crossroad, 1981
Dunstan G.R. & Shineborne E.A.
(eds): Doctors’ Decisions: Ethical Conflicts in Medical Practice, 1989
Engelhardt H.T.: The Foundations of
Engelhardt H.T.: Bioethics and
Secular Humanism: The Search for a Common Morality, 1991
Fletcher J.F.: Morals and Medicine, Boston: Beacon Press,
Gelfand M.: Philosophy and Ethics of
Churchill Livingstone, 1968
Gillon R.: Philosophical Medical
Gillon R. (ed): Principles of Health
Care Ethics, Chichester: John Wiley & Sons, 1994
Gorovitz S.: Doctor’s Dilemmas: Moral
Conflict and Medical Care, 1982
Gorovitz S., et al. (eds):
Moral Problems in Medicine, 2nd ed, Engelwood Cliffs: Prentice-Hall, 1983
Hering B.: Medical Ethics, Notre
Hunt R. & Assas J.: Ethical
Issues in Modern Medicine, Mayfield Pub Com, 1977
Jonsen A.R., et al. Clinical
Ethics, 3rd ed, New York:
McGraw Hill, 1992
Mappes T.A. & Zembaty J.S.:
Biomedical Ethics, 3rd ed, New York:
McGraw Hill, 1991
Monagle J.F. & Thomasma
D.C.: Medical Ethics, Rockville:
Aspen Pub, 1988
Pellegrino E.D. & Thomasma D.C.:
A Philosophical Basis of Medical Practice, 1981
Pellegrino E.D. & Thomasma D.C.: For the
Patient’s Good, New York:
Oxford University Press, 1988
Ramsey P.: The Patient as a Person, New Haven: Yale
University Press, 1970
Reich W.T. (ed): Encyclopedia of
Bioethics, New York:
The Free Press, 1978
Reiser S.J., et al. (eds):
Ethics in Medicine: Historical Perspec- tives and Contemporary Concerns, Cambridge: MIT Press,
Shannon T.A. (ed): Bioethics, Ramsey:
Paulist Press, 1981
Sperry W.L.: The Ethical Basis of
Medical Practice, 1950
Spicker S.F. & Engelhardt H.T.
(eds): Philosophical and Medical Ethics: Its Nature and Significance, 1977
Veatch R.M. (ed): Medical Ethics, Boston: Jones &
Walters L. & Kahn T.J. (eds): Bibliography
of Bioethics, Washington,
D.C.: Kennedy Institute of
Ethics, Yearly volumes
2. A variety of journals are
devoted to medical ethics. These include:
Bibliography of Bioethics
Bioethics Literature Review
Bioethics Research Notes
Cambridge Quarterly of Healthcare and Ethics
Ethics in Science and Medicine
Hastings Center Report
Journal of Health Politics, Policies
Journal of Medical Ethics
Journal of Medicine and Philosophy
Journal of Religion and Health
Man and Medicine
Source: Prof. A. Steinberg, The
entry “Ethics, Secular”
from the Encyclopedia of Jewish Medical Ethics.
For further halachic details and references — see Hebrew Edition of the
Encyclopedia, Vol. 6, 1998, pp. 646-692 (Schlesinger Institute); English
Edition of the Encyclopedia, Vol. II, 2003, pp. 389-404 (Feldheim Publishers)