An Introduction to Biomedical Ethics
Ethical theories represent the grand ideas on which guiding principles are based. They attempt to be coherent and systematic, striving to answer the fundamental practical ethical questions:
What ought I do?
How ought I live?
Generally ethical principles stem from ethical theories, and when defending a particular action, ethicists normally appeal to these principles, not the underlying theory. Ethical traditions stretch back to earliest recorded history. Separate bodies of ethics, often not encompassing a true theory but rather a general system, were developed in India and China, and within the Jewish, Christian, Islamic, and Buddhist and Hindu religions. All of these theories represent altruistic, rather than egoistic, attitudes towards mankind. Some of the most commonly cited ethical theories include the following:
The system of natural law, often attributed to Aristotle, posits that man should live life according to an inherent human nature. It can be contrasted with man-made, or judicial, law, but they are similar in that both may change over time, despite the frequent claim that natural law is immutable, often tying it to particular religious beliefs.
Deontology holds that the most important aspects of our lives are governed by certain unbreakable moral rules. Deontologists hold that these rules may not be broken, even if breaking them may improve an outcome. In other words, they may do the "right" thing, even though the consequences of that action may not be "good." The famous philosopher, Immanuel Kant is often identified with this theory. One example of a list of "unbreakable" rules is the Ten Commandments.
One of the more functional and commonly used theories, utilitarianism, sometimes called consequentialism or teleology, basically promotes good or valued ends, rather than using the right means. This theory instructs adherents to work for those outcomes that will give the most advantage to the majority of those affected in the most impartial way possible. (Simplistically, this theory advocates achieving the greatest good for the greatest number of people.) It is often advocated as the basis for broad social policies.
The virtue theory asks what a "good person" would do in specific real-life situations. This recently revived theory stems from the character traits discussed by Aristotle, Plato, and Thomas Aquinas. They discuss such timeless and cross-cultural virtues as courage, temperance, wisdom, justice, faith, and charity.
Values And Principles
Values are the standards by which we judge human behavior. They are, in other words, moral rules, promoting those things thought of as good and minimizing or avoiding those things thought of as bad. We usually learn these values at an early age, from observing behavior and through secular (including professional) and religious education. Societal institutions incorporate and promulgate values often attempting to make old values rigid, even in a changing society. In a pluralistic society, clinicians often treat subjects having multiple and differing value systems, and they must be sensitive to others’ beliefs and traditions.
Ethical values stem from ethical principles. Ethical principles are action guides derived from ethical theories. Each of these principles consists of various moral rules, which are our learned values. For example, the values of dealing honestly with patients; fully informing patients before procedures, therapy, or being involved in research; and respecting the patient’s personal values are all subsumed under the principle of autonomy or respect for persons.
Although each person is entitled (and perhaps even required) to have a personal system of values, there are certain values that have become generally accepted by the medical community, courts, legislatures, and society at large. A respect for patients (often described as patient autonomy) has been considered so fundamental that it is often given overriding importance. Although some groups disagree about each of the generally accepted values, this dissension has not affected their application to medical care.
Assessing Patient Values
A key to making ethical decisions at the bedside is to know what the patient’s values are. In patients too young or incompetent to express their values, it may be necessary for physicians to make general assumptions about what the normal person would want in a specific situation or to rely on surrogate decision making. With patients who are able to communicate, however, care must be taken to discover what their own uncoerced values really are.
A typical ethically dangerous scenario is with a patient who refuses lifesaving medical intervention "on religious grounds." Typically, the spouse is at the bedside, does most of the talking, and may be influencing the patient’s decision. In those cases, it is incumbent on the clinician to question the patient alone to assess his or her real values.