An Introduction to Biomedical Ethics
Clinical bioethical reasoning is primarily case based. Much like clinical practice that relies both on general rules and case-based experiences, bioethical reasoning relies on learned and accepted moral rules, prior bioethical decisions derived from thoughtful reflection, and a recognition of unique factors in individual situations that differentiate one case from another. This method of case-based reasoning is termed casuistry, although physicians may better know it as clinical reasoning. When clinicians think of bioethics, they often think either of the legal bases for their actions both prescriptive and proscriptive or their religious background. Neither directly applies. Rather, clinicians are obligated to make patient-centered, value-driven ethical decisions.
Bioethics and the law
How does bioethics differ from law? Both give rules of conduct to follow. Laws stem from legislative statutes, administrative agency rules, or court decisions, and they often vary in different locales and are enforceable only in those jurisdictions where they prevail. Ethics incorporates the broad values and beliefs of correct conduct. Although bioethical principles do not change because of geography (at least not within one culture), interpretation of the principles may evolve as societies change. This same evolution occurs within the law. Good ethics often makes good law, whereas good law does not necessarily make good ethics. Although societal values are incorporated into both the law and within ethical principles and decisions, ethical principles are basic to society. Most laws, although based loosely on societal principles, are actually derived from other laws.
Significant overlap exists between legal and ethical decision making. Both ethical analysis (in bioethics committee deliberations) and the law (in the courts) use case-based reasoning in an attempt to achieve consistency. Legal and ethical dicta have existed since ancient time, have evolved over time, incorporate basic societal values, and form the basis for policy development within health care as well as in other parts of society.
The law and bioethics differ markedly, however, in some areas. For instance, the law operates under formal adversarial process rules, such as those in the courtroom, which allow little room for deviation, whereas bioethics consultations are flexible enough to conform to the needs of each institution and circumstance, and, rather than being adversarial, are designed to assist all parties involved in the process. The law also has some unalterable directives, sometimes called black-letter law, that require specific actions. Bioethics, although based on principles, is designed to weigh every specific situation on its own merits. Perhaps the key difference between bioethics and the law is that bioethics relies heavily on the individual person’s values-the patients’ or their surrogates’. Also, even without the intervention of trained bioethicists, medical personnel can and often should be able to make ethically sound decisions. The law does not consider individual values and generally requires lawyers for interpretation.
Bioethics and Religion In homogenous societies, religions have long been the arbiters of ethical norms. In multicultural societies, with no single religion holding sway over the entire populace, a patient value-based approach to ethical issues is necessary. Religion still influences bioethics, however. Modern bioethics uses many decision-making methods, arguments, and ideals that originated from religion. In addition, clinicians’ personal spirituality may allow them to relate better to patients and families in crisis. Although various religions may appear dissimilar, most have a form of the Golden Rule, or a basic tenet that holds, "do unto others as you would have them do unto you." Moral rules govern actions that are immoral to do without an adequate moral reason and can justifiably be enforced and their violation punished. Although none of these rules is absolute, they all require one to not cause evil. Somewhat paradoxically, however, they may neither require preventing evil nor doing good.
1. Do not kill.
2. Do not cause pain.
3. Do not disable.
4. Do not deprive of freedom.
5. Do not deprive of pleasure.
6. Do not deceive.
7. Keep your promise.
8. Do not cheat.
9. Obey the law.
10. Do your duty.
Problems surface when trying to apply religion-based rules to specific bioethical situations. For example, although "do not kill" is generally accepted, the interpretation of the activities that constitute killing, active or passive euthanasia, or merely reasonable medical care vary with the world’s religions, as they do among various philosophers. Therefore several generally accepted secular principles have emerged, such as autonomy, beneficence, nonmaleficence, and fairness, which have guided ethical thinking over the past three decades.