Medical Ethics

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MEDICAL ETHICS

MEDICAL ETHICS . Religious beliefs are central to the process of deliberation in medical ethics. An awareness of the rich diversity of perspectives both within and among different religious traditions is critical to the development of respectful dialogue. This entry will focus on the religious traditions of Christianity, Judaism, and Islam. Readers interested in Hinduism are referred to S. Cromwell Crawford's Hindu Bioethics for the Twenty-First Century (2003) and those interested in Buddhism are referred to Damien Keown's Buddhism and Bioethics (1995).

Overview of Medical Ethics

Medical ethics is the application of principles and rules of morality to healthcare (Clouser, 1974). It is a multidisciplinary field grappling with perplexing questions created by rapidly evolving scientific, technological, and social developments. There is not a single systematic theory of medical ethics. Rather, medical ethics has matured into a discipline that is enriched by a plurality of voices from clinical medicine, religious traditions, philosophy, literature, politics, and the social sciences.

One of the earliest articulations of ethical guidance for physicians is the oath of Hippocrates, which dates from as early as the fourth century bce. Two statements in the Hippocratic oath—"into whatsoever house you shall enter, it shall be for the good of the sick to the utmost of your power" and "you will exercise my art solely for the cure of patients"—are the basis for the well-known principle of "above all do no harm" when caring for patients (Dorman, 1995; Carey, 1928).

In contrast to the personal expression of ideal conduct embodied in the Hippocratic oath, in 1803 Thomas Percival published Medical Ethics or a Code of Institutes and Precepts (Percival, 2000). This code became the basis of the American Medical Association's first Code of Ethics adopted in 1847 (Baker, 2000). The development of a code of ethics marked a radical transition from a personal ethic that focused primarily on elucidating the proper demeanor for physicians (Jonsen, 2000) to a collective professional ethic that renewed concern for the place of values in the practice of medicine.

By the middle of the twentieth century advances in medical science radically changed the ability of physicians to diagnose and treat illness. These developments created a moral crisis that cried out for a rethinking of the moral obligations of physicians. Notably, the condemnation of research without patient consent, codified as the Nuremberg Code in 1947, transformed the interaction of physician-investigators and patients in research. In 1950 an era of organ transplantation began, eventually forcing society to reassess the definition and criteria for death (Defining Death, 1981). In 1953 the structure of DNA was discovered and set the groundwork for the genetic revolution in the early twenty-first century. In 1961 hemodialysis became a reality, raising questions about the allocation of scarce resources and the appropriateness of using technology to prolong life. In 1973 the U.S. Supreme Court's Roe v. Wade decision affirmed the right of a woman to obtain an abortion during the first trimester of pregnancy. The 1970s also ushered in vigorous debates about who should live and who should be allowed to forgo lifesaving treatment. These questions were stimulated by the seminal cases of Karen Quinlan (Quinlan 70 NJ, 335A2d, 1976) and Donald "Dax" Cowart (Kliever, 1989) and continued into the 1990s with questions about the ethics of euthanasia and assisted suicide (Deciding to Forgo Life-Sustaining Treatment, 1982; Washington et al. v. Glucksberg et al., 1997; and Vacco, Attorney General of New York, et al. v. Quill et al., 1997). More recently, greater emphasis has been placed on the quality of end-of-life care and how to improve it. The advent of managed care has invigorated debates on resource allocation and the role of physicians as managers. The twenty-first century heralded in an era of genetics with the mapping of the human genome and questions about the acceptability of stem cell research and cloning (Shapiro, 1999; Nuffield Council on Bioethics, 2000). These questions are part of a gradual shift in the discipline from internal professional concerns to matters of public debate.

Religious Approaches to Medical Ethics

Theologians were among the first to contribute to the modern dialogue of medical ethics, and they were instrumental in shaping the emergence of the discipline (Callahan, 1990). Religious approaches to medical ethics share a common grounding of ethical positions in religiously based claims (Lammers, 1998; Williams, 1997). A brief discussion of the theological principles that guide each religion's vision of healthcare follows.

Catholic medical ethics

There is a long tradition of Catholic medical ethics dating from Augustine's writings on suicide and Thomas Aquinas's doctrine of natural law to modern-day directives on euthanasia and reproductive technologies (O'Rourke, 1999). The church's ethical and religious directives govern Catholic medical ethics (Ethical and Religious Directives for Catholic Health Care Services, 2001). The directives are grounded in the natural law approach of Catholic moral theology from which the church has derived its understanding of the nature of the human person, of human acts, and of the goals that shape human activity.

Fundamental to Catholic bioethics is a belief in the sanctity of life. Life is understood as a gift from God, and human beings are its steward (Wildes, 1997). The Catholic belief in the resurrection of Christ and an afterlife, however, influences the attitude toward life. Catholicism believes that human life and personhood begin at conception. Thus, a human fetus at any stage of development is a person who has a right to life. Central to Catholicism is a belief in a metaphysical conception of human beings as both body and soul. The presence of a living body, even if it has diminished or absent intellectual capabilities, is the defining characteristic of personhood. This belief has implications for ethical questions at the beginning and end of life.

As in most religions, there is a diversity of opinion within Catholicism. Richard McCormick has articulated a teleological ethic in which good is judged in relation to the common good. He argues for a proportionalist perspective in which an action viewed as evil might be justifiable if it brings about a good that is proportionate to or greater than the associated evil (McCormick, 1981b). This position is in opposition to Catholic beliefs in the absolute ontic nature of moral acts. McCormick has a dynamic understanding of Catholic theology that emphasizes an individualized and context-sensitive approach to moral problems (May, 1987 and 1994). According to McCormick actions should be judged based on what values they advance or denigrate within the context of an objective hierarchy of values (Rae, 1999). McCormick connects moral values to moral rights and duties. Thus the right to self-determination is linked to the moral value of human freedom.

Protestant medical ethics

Protestant medical ethics is rooted in the teachings of Martin Luther and such Reformation themes as "the freedom of a Christian," as well as biblical principles, such as love (Johnson, 1978). There are many strains of Protestant theology, and so there are diverse approaches to Protestant medical ethics. It is therefore difficult to define a uniquely Protestant approach to medical ethics, and most Protestants would view secular medical ethics as compatible with their personal religious beliefs (Pauls and Hutchinson, 2002). Paul Ramsey and James Gustafson are two prominent Protestant thinkers who have developed a Protestant approach to medical ethics. Ramsey develops an ethic that is rooted in the biblical concept of a covenantal relationship and the biblical conception of righteousness. His ethical positions are directed at meeting the needs of others (Ramsey, 1950). It is therefore not surprising that he focuses on the obligations of physicians to patients and those of researchers to human subjects. He leaves no room for consideration of the common good that might diminish the priority of care for individual patients. The individual's welfare is always first and foremost (Ramsey, 1970b). Ramsey also developed a phenomenological conception of Protestant natural law and argues that natural laws are discovered "in the course of active reflection upon man in the context of moral, social, and legal decisions" (Ramsey, 1962, p. 216). This is consistent with the historical Protestant emphasis on personal freedom and has contributed to the establishment of patient autonomy as a central concept within the moral framework of medical decision-making.

James Gustafson has emphasized the web of human relationships in which individuals are situated (Gustafson, 1965). The starting place for his ethical reflection is ordinary human existence rather than church doctrines or scriptural passages; nevertheless, Gustafson developed a theocentric ethic. Although he argued that Christian ethics should begin with human experience, human action should be judged primarily by the will of God and not by the welfare of human beings.

Jewish medical ethics

Jewish medical ethics is rooted in the application of the scriptural texts of the Five Books of Moses, the Talmud, codes of Jewish law, and the responsa literature to contemporary ethical questions in medicine. The Talmud is the primary sourcebook of Jewish law; it entails expositions and debates by rabbis about how to apply principles to different circumstances. The responsa literature is a compilation of written decisions and rulings by rabbis in response to questions posed about Jewish law. The questions are usually practical, and often concern new situations for which no provision had been made in prior codes of law. Responsa begin to appear in the sixth century ce, and all denominations within Judaism continue to formulate responsa. In recent years they have addressed many contemporary questions relating to medical ethics.

The presence of a well-defined corpus of religious legal texts does not mean, however, that there is one authoritative Jewish position on questions of medical ethics. Within Orthodox Judaism (Freedman, 1999; Waldenberg, 1963) and among Orthodox, Conservative, Reform, and Reconstructionist Judaism there is a diversity of opinions on how to apply traditional sources to contemporary ethical problems. For some, Jewish medical ethics is constrained by the scriptural rules and precedents accumulated over thousands of years (Tendler, 1998; Jakobovits, 1975; Rosner, 1979). This approach is in tension with those who look more broadly at the values behind Jewish law and apply them to modern-day situations (Newman, 1995; Zohar, 1997; Gordis, 1989). What sources are selected and what methodological approach is used in the interpretation of traditional Jewish texts will influence the ethical decision that is reached. Jewish ethicists dispute fundamental questions about how concrete examples discussed in the Talmud can be extrapolated to modern-day questions in medical ethics.

In an effort to grapple with contemporary questions from a Jewish perspective, Elliott Dorff (1998) has articulated several fundamental beliefs underlying Jewish medical ethics. He argues that the following beliefs should inform the Jewish response to modern-day questions in medical ethics: a belief that human bodies belong to God, human worth flows from being created in the image of God, the human being is an integrated whole where body and soul are judged as one, the body is morally neutral and potentially good, there is an obligation to heal, and Jews have an obligation to engage in action that sanctifies God's name. Dorff thus puts forth a methodology of Jewish medical ethics that goes beyond strict legalism. He interprets Judaism's general rules not as inviolable principles, but as guiding policies that need to be applied with sensitivity to the contexts of specific medical cases.

Islamic medical ethics

Islamic medical ethics is based on sharī ʿah, Islamic law, which is founded on the Qurʾān and the sunnah. The Qurʾān is the holy book of all Muslims, and the sunnah contains aspects of Islamic law based on the prophet Muḥammad's teachings. As in Judaism, Muslim scholars of religious law are called upon to determine religious practice and resolve questions in medical ethics. The application and interpretation of Islamic law is dynamic and flexible within the confines of a sacred set of values and texts (Van Bommel, 1999). In 1982 Abdul Rahman C. Amine, M.D., and Ahmed Elkadi, M.D., proposed an Islamic code of medical ethics that addresses many fundamental questions in contemporary medical ethics (Rahman, 1982). In Islam, life is sacred and every moment has value even where the quality of life is diminished. Full human life begins after the ensoulment of the fetus, and most Muslim scholars agree that this occurs at about 120 days after conception (Al Bar, 1986). A minority of scholars believes that ensoulment occurs at forty days after conception (Al Bar, 1995). Saving a life is considered a duty informed by the guiding principle mentioned in both the Qurʾān and in the Talmud, "If anyone has saved a life, it would be as if he has saved the life of the whole of mankind" (Qurʾān 5:35; and Mishnah Sanhedrin 4:5). Death is considered to occur when the soul leaves the body, but since this cannot be determined with certainty, physical signs are used to diagnose death. The concept of brain death was accepted by a majority of Islamic scholars in 1986 (Al Bar, 1995).

Reproduction

Many religious traditions share the assumption that human life is sacred. This understanding of life has implications for the permissibility of abortion. Catholicism's official opposition to abortion has been based on two fundamental beliefs (Pope John Paul II, 1995). One is the belief that a human fetus is a person from the moment of conception, and thus aborting a fetus is tantamount to murder. The Second Vatican Council (1962–1965) condemned abortion unconditionally as an "unspeakable crime" (Pope Paul VI, 1965). The second belief that underlies the Catholic position on abortion, contraception, and assisted reproduction is that sex is permitted only when it is integrated into marriage and has procreative intent. In opposition to the antiabortion stance of the church, some Catholic theologians have tried to revive a more liberal position that claims that the male fetus acquires a soul forty days after conception, while the female fetus only acquires a soul eighty days after conception (Dombrowski, 2000). This position is based on the teachings of Augustine of Hippo (354–430), and it is strikingly similar to Jewish understandings of the fetus, but it was never held as a universal truth by everyone in the church.

Protestant views on abortion are diverse. Conservative groups believe that life begins at conception; however, some liberal denominations are pro-choice, believing that freedom of choice is an important principle. Exceptions to the duty to preserve life include medical indications, pregnancy resulting from rape, or social and emotional conditions that would not be beneficial to the mother or future child (Gustafson, 1970).

In Jewish law an embryo is considered to be mere water until the fortieth day (Epstein, 1935–1952). This leads some to argue that abortion is permissible during the first forty days of pregnancy (Responsa Seridei Esh, 1966). A fetus has the status of a potential human life, and thus Judaism permits abortion under certain circumstances. Where the mother's life is in jeopardy, abortion is mandatory. The Talmud speaks directly to this question where it says: "if the fetus threatens the life of the mother, you cut it up within her body and remove it limb by limb if necessary, because its life is not as valuable as hers. But once the greater part of the body has emerged, you cannot take its life to save the mother's, because you cannot choose between one human life and another" (Mishnah Ohalot 7:6). Thus a fetus becomes a person when the head emerges from the womb. As with most questions in Judaism, there is a diversity of opinion on when abortion is permitted (Feldman, 1980; Lubarsky, 1984; Bleich, 1968). Some authorities permit abortion in the case of rape, and some will permit abortion in the first trimester if the fetus would be born with an abnormality that would cause it to suffer. One Orthodox authority has argued that abortion is permissible until the end of the second trimester if the fetus has a genetic mutation that would be lethal and would cause great suffering (Waldenberg, 1980).

Islam discourages abortion, but permits it under certain circumstances. Abortion has been allowed after implantation and before ensoulment in cases where there are adequate reasons. However, many Shīʿah and some Sunnis have prohibited abortion after implantation unless the mother's life is in danger (Ebrahim, 1989).

End-of-Life Care

Advances in medical technology have made it possible to prolong life through the use of ventilators, artificial organs, intravenous feeding, and ventricular assist devices. The monotheistic religions of Judaism, Christianity, and Islam uphold a duty to protect life that is on temporary hold from God. These faiths have uniformly rejected suicide. Within the Catholic tradition the failure to use ordinary measures to preserve life is morally equivalent to suicide. This does not imply, however, that there is a duty to prolong life in all circumstances, regardless of the patient's condition. Catholic theologians have distinguished ordinary and extraordinary life support, arguing that a person is obligated to use ordinary measures but that there is room for choice with regard to the use of extraordinary measures (Cronin, 1958). The directives outline compassionate care for the dying, which includes pain management but also respects informed and competent refusal of life-sustaining treatment. McCormick argues that Catholic moral theory connects self-determination with the duty to preserve life, but it places limits on this duty. "Life is indeed a basic and precious good, but a good to be preserved precisely at the condition of other values" (McCormick, 1981a, p. 345). He affirms the right of competent patients to reject life-sustaining treatment, arguing that individual patients will be in the best position to determine which treatments have a reasonable benefit and which treatments are accompanied by an unreasonable burden. McCormick urges patients to make a proportionate, reasoned decision in considering the rejection of life-sustaining treatment. This would include a consideration of the value of preserving life, human freedom, and lack of pain (McCormick, 1981a, p. 399).

Gustafson argues that life is not an absolute value, and yet he is also quick to say that life is the "indispensable condition for human values and valuing" (1971, p. 140). Thus we should neither worship life nor should we be quick to end life. Gustafson puts forth four religious qualifications to consider about life and death: (1) Life is a gift since human beings are dependent creatures; (2) Only God is absolute, and human life is of relative worth; (3) Human beings are accountable to God and responsible for how they treat life; (4) Human beings are participants in life who must respond to the developments and purposes that are made possible by God (Gustafson, 1968).

Jewish perspectives on end-of-life care are also informed by a belief that human life is sacred, and thus the preservation of life surpasses almost all other commandments. Most would argue, however, that this belief does not translate into a mandate to preserve all human life under all circumstances and at all costs (Herring, 1984). Although hastening death is prohibited, if something is an impediment to the natural process of death, it is permitted to withdraw that impediment. For example, if a person is certain to die, and is only being kept alive by a ventilator, it is permissible to withdraw the ventilator, which is impeding the natural process of death. Judaism attempts to balance the thrust to prolong life and the recognition that life may become unbearably difficult and painful (Rosner, 1979).

Islam considers the intentional hastening of death to be the equivalent of murder and thus denounces suicide and assisted suicide (Ebrahim, 2000). Islam does not condone the secular concept of a right to die. Like Judaism, however, Islam acknowledges that when treatment becomes futile, it ceases to be mandatory. A patient may refuse treatment when it will not improve his condition or quality of life. Although continued medical care, including the use of a ventilator may not be required, hydration, nutrition, and pain control should not be withheld (Khomeini, 1998).

Genetics

The completion of the finished sequence of the Human Genome Project in 2003 marks the beginning of a new era of genetic manipulation. The potential for disease prevention, early detection, and improved treatment of diseases for which there is an identified genetic basis, however, is accompanied by concern about the ethical, social, legal, and psychological implications of genetic information (Andrews et al., 1994). One of the most promising and controversial areas of genetics is stem cell research. Stem cells are unique in their ability to differentiate into any cell of the human body. They have been isolated from adults, aborted fetuses, and embryos shortly after conception, and many believe stem cells are the key to developing treatments and cures for some diseases. Others, however, argue that using these cells is the equivalent of taking a human life, and even if their use leads to saving lives, it is not morally permissible to destroy embryonic stem cells.

Embedded within religious perspectives on the use of stem cells and cloning are varying theological assumptions that each religion has about a human embryo, the religious duty to procreate, and the relationship between human beings and technology. These assumptions lead to varied conclusions about the permissibility of stem cell research and cloning.

The Catholic Church has been unequivocal in its denunciation of the use of embryonic stem cells. This position is based on the belief that human life begins at conception and thus embryos must be respected (Donum Vitae, 1987). Because Protestant theology is pluralistic, there is not a unified position on the use of embryonic stem cells. The general synods of the United Church of Christ have regarded human embryos as due great respect, but they have not regarded embryos as the equivalent of a person (Cole-Turner, 1997). Other Protestant views consider the dangers of not respecting the weakest human being, namely the embryo, to be greater than any medical benefit that might be achieved through stem cell research.

Since Judaism does not consider an embryo to have significant moral status prior to forty days of gestation, the majority of Jewish authorities believe that embryos may be used for research (National Bioethics Advisory Commission, 1999; Breitowitz, 1996).

The successful cloning in 1996 of Dolly the sheep through the somatic cell nuclear transfer technique has raised the possibility of cloning humans. Some Catholic and Protestant thinkers have reiterated past opposition to cloning (Cahill, 1997; Verhey, 1994; Ramsey, 1966 and 1970a). The foundations of these claims are an opposition to "playing God," the view that cloning represents a violation of the unitive aspect of marriage, and a belief that cloning is a violation of human dignity (Haas, 1997; Moraczewski, 1997).

However, some Protestant thinkers have expressed qualified support for cloning research and for creating children using somatic cell nuclear transfer techniques. This view is based on an understanding of the meaning of human partnership with ongoing divine creative activity. Ted Peters argues that human begins are called to "play human" and assume the role of co-creator through the acquisition of knowledge aimed at improving humanity (Peters, 1996). According to this view there are no theological principles that the cloning of humans necessarily violates.

Jewish perspectives on cloning are guided by the biblical injunction to procreate and "master the world" (Gn. 1:28). The fulfillment of this biblical mandate is understood as permitting people to modify nature to make the world a better place (Dorff, 1997). Cloning is one example of mastery over the world, and it is not theologically problematic in the Jewish tradition (Tendler, 1997; Luria, 1971).

The model of a partnership with God in the creative process also appears in Islamic thought (Sachedina, 1997). Understood in this light, cloning may in some circumstances be an example of using human creative potential for good. Islamic scholars have argued that scientific discovery is ultimately a revelation of the divinely ordained creation. Scientific knowledge is therefore understood as a symbol of God's creation and an opportunity given by God to human beings (Hathout, 1997).

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