Medical Ethics: an Inclusice History
As long as there has been some form of medical treatment in the world, there has been someone who has voiced their ethical viewpoints on the treatment of patients. It is difficult to trace back the very first ethical thinking in medicine, but Islamic and Muslim traditions have left their footprints in Medical and Bioethics since before the medieval and early modern period. The first piece of literature ever dedicated to the field of medical ethics was written in the 9th Century by Ishaq bin Ali Rahawi and was titled Adab al-Tabib or Conduct of a Physician.
Ali Rahawi reffered to physicians as guardians of the soul and body. One of the features in medieval Muslim medicine that separated their practices from their colleagues was their higher standards of medical ethics. Hospitals of the Islamic world made it their duty to treat patients regardless of their wealth, religious, and ethnic backgrounds. Even the Islamic hospitals employed staff from Christian, Jewish and other marginal backgrounds. After reading a portion of Conduct of a Physician I came across this passage which is in some way the Islamic for of the Hippocratic Oath (Howard, 1997).
Scientists are accountable to God for their activities, they are required both to serve the community and to protect and promote its ethical and moral institutions. The way they use science, therefore, must reflect the values of the society they seek to serve. Thus, the Quranic approach to science is at once dynamic and static: it promotes reason, objectivity and the pursuit of truth and excellence, but at the same time, it places this endeavour firmly within the boundaries of Islamic ethics and values.. ” – Ishaq bin Ali Rahawi
Evident in this passage, it is easy to see the importance of the pursuit of knowledge in Islamic tradition. This is not to say that this knowledge is submissive to the Qur’an and its values. According to the Qur’an, those who possess knowledge united with faith and practice, are promised good rewards along with high rank in the medical field. Islamic science is the practical knowledge that produces results and leads to virtue (The Message of the Qur’an, 2008).
The Conduct of a Physician includes what the phyisican must void and be aware of, the manners that visitors must demonstrate, the dignity of the medical profession, the examining and removal of corruption among physicians. The Muslim physician who worked closely with Ali Rahawi, Fakhr al-Din al-Razi did much to personalize medicine by taking into consideration the patient’s problems and attitudes. He believed that the doctor’s aim was to do good even to our enemies, even more so our friends. The profession and the work that goes along with it forbids us to do harm to our loved ones because it is instituted for the benefit and welfare of the human race.
Al-Razi stressed that doctors did not have the answers to all medical problems and could not heal all sickness and disease. To become more useful and to make the best ethical decisions, he advises physicians to keep up with advanced knowledge and to study medical books and expose themselves to new cases. He also states that the physician should not be blamed when he is unable to cure diseases such as cancer or leprosy because this makes it even more difficult to treat patients in the future (Iskenderoglu, 2002).
Throughout time, there have been numerous cases and figures who have contributed in numerous ways to the development of our modern healthcare codes and ethics. The first of these men was Immanuel Kant who developed his idea of Kantian Ethics which is used to argue for the right to healthcare. The basis behind his ethics is that everyone has an intrinsic worth and dignity which should never be tarnished. From this arose his idea of duties which according to Kant, is what gives rise to our rights and determines what we can demand of others.
Because of this duty, everybody has the right to healthcare and it is up to society to have this duty met. Kant also created his categorical imperative which is a rule for determining what is right. Kant also formulated his idea that human beings should always treat each other as ends and not as means only. Basically, everybody should have the right to heal care because turning somebody away because they cannot pay or whatnot would be treating them as a means and not as an end.
To properly treat people as an end would be to offer everybody healthcare regardless of their wealth (Heubel et al. 005). Thomas Aquinas was known in the medical field for his law ethics and cardinal virtues. The cardinal virtues of prudence, temperance, justice, and fortitude were all defined by Aquinas. He stated that the virtues are natural and revealed in nature, and they are binding on everyone. He also defined three supernatural virtues of faith, hope and charity which he called supernatural virtues. Additionally, Aquinas distinguished four types of law which were eternal, natural, human and divine.
Eternal Law stems from the declaration that God governs all creation and Natural Law is the human participation in eternal law and is revealed through reason (Pojman, 1995). Among the natural human values of which all values originate are the desire to live and the aspiration to produce offspring. Although he was for procreation, he was against sexual activity not for the purpose of creating a child such as masturbation and oral sex. His theories greatly influenced the Catholic perspective on mortal sin (Grabmann, 2007).
Another more modern influential character in the field of medical ethics is Jack Kevorkian also referred to as “Doctor Death. ” During the 1990’s Jack Kevorkian was unquestionably the most prominent figure in the support of assisted suicide and euthanasia. Kevorkian made headlines internationally when he undertook a well publicized assisted-suicide campaign between 1990 and 1998 that reportedly ended the lives of approximately one hundred thirty people. Some of those whose deaths Kevorkian facilitated were terminally ill and diagnosed as having less than six months to live, but most were disabled or chronically ill.
He would hook his patients up to a “Suicide-Machine” that would result in a painless death. Though controversial, his contributions to the ethical issues of Physician Assisted Suicide and Euthanasia are unparalleled. This issue brought light to people’s free will in choosing death over life and was a key influence in hospitals allowing patients to fill out advanced directives. His work raised the question of whether euthanasia should be legalized and if it is ethical.
The media interest brought on by this case illuminated issues such as “Dying with Dignity” and the “Right to Die Movement. Though his work faced immense opposition, he is still regarded as one of the most influential figures in modern healthcare ethics (Betzold, 1993). Yet another major figure in the field of medical ethics was Hippocrates who is believed to have written the Hippocratic Oath. The Hippocratic oath is a sworn statement that doctors make even today to practice medicine in an ethical manner. It requires a new physician to swear upon a number of healing gods that he will uphold a number of professional ethical standards.
The text teaches of a moral code to practice by, tandpoints on abortion, surgery, and confidentiality. In the text it states that “And likewise I will not give a woman a destructive pessary. ” A pessary was a soaked piece of cloth inserted in the vagina to induce abortion. It is debated on whether Hippocrates had an objection to the method of abortion or to abortion in general. The next sentence “In a pure and holy way, I will guard my life and my art and science,” teaches that doctors should desist from immoral behavior and resist the temptations that come with opportunity (Miles, 2005).
Other influential figures in Medical Ethics include Joseph Fletcher who was a pioneer in the field of bioethics, abortion, Eugenics, Euthanasia and founded the theory of situational ethics, Thomas Percival who created the first modern code of Medical Ethics, and Ishaq bin Ali Rahawi, who wrote the Adab al-Tabib , the first treatise dedicated to medical ethics. The root of all ethics in my opinion stems from the influence of religion and culture. I believe that it is impossible to separate your religion and your ethics and morals. Many of these influences are still evident today in hospitals around the world.
Culture and religion matter greatly in making healthcare decisions because there is strong evidence of health inequalities along race, religion, and ethnicity. There are systematically worse health outcomes for members of minority racial and ethnic groups and greater dissatisfaction with health services expressed by members of minority groups. To see the larger picture of the role culture and religion play, in the last 20 years, healthcare providers have taken culture and religion into account though oversimplified models. They tend to view culture as unchanging and static which is the farthest thing from the truth.
According to Kleinman (2004), culture is an acute attentiveness in different situations to what is most at stake; it is the passionate development of interpersonal connection, the serious performance of religious practices, and the cultivation of individual and shared identities. It is inseparable from economic, political, psychological, and biological conditions and affects and is affected by all. Doctors who treat culture and religion as homogenous are ignorant to the fact that cultural meanings and practices differ within the same group because of age, gender, politics, religion, and personality.
At an earlier period in health care, culture referred only to the culture of the patient and family but now it has been demonstrated that the culture of the professional caregiver has importance. This biomedical culture is expressed in hospitals, clinics, medical schools and are seen as huge players in problems between patient-physician relations, communication, institutional racism, and the development of health disparities (Kleinman, 2004 ). The reason why cultures have become important in bioethics is also that there appear to be differing viewpoints and judgments from various cultures regarding many bioethical problems.
An example of how culture affects our heath care decisions is apparent in the west where it is customary to take the elderly who are unable to properly care for themselves to nursing homes. This is in contrast to eastern culture such as in Thailand, where such a practice is frowned upon. They believe that a nursing home is a place where the elderly are neglected and abandoned by their children. In a BBC news article that I read recently, I learned of the banned Indian practice of Sati. This practice involved widows throwing themselves into their husband’s funeral pyre to show their love and devotion.
As soon as the British learned of this practice, they banned it. The problem here is that among all the thousands of traditions, which practice is considered right and who are to say? In Leonard Swidler’s article “Toward a Universal Declaration of a Global Ethic,” he states that Immanuel Kant believes that universal ethics is not possible, but is necessary for otherwise ethics itself would not be possible at all. He claims that there must be a system of universal ethics since all human beings are capable of reasoning and reasoning presupposes that there be such a universal system (54).
Stem cell research is one of the most powerful examples of the differences between culture and healthcare. The debate here is usually seen as a struggle between the quest for scientific progress and ethical concerns of protecting humans. The root of the problem is whether or not an embryo is a human being or if it is just a collection of cells similar to those of skin cells which we lose every day. This example shows that arguments based on culture alone can lead to nowhere except deep disagreement.
As human beings interact, it is almost impossible to keep your set of cultures intact, therefore the ethical attitudes in one culture can change as a result of this combination among cultures. It is relevant to study the history of ethics as pertains to healthcare because many of our medical issues stem from differences in our opinions and these differences in ethics need to be accounted for. By studying the History of ethics in the medical field, we are able to have a wealth of knowledge of past incidents and the decisions that were made in those situations.
There will always be opposition to every decision anybody makes in the healthcare field whether it be justified or not. Early medicine was a close integration of medical expertise and medical ethics those who engaged in research and experiments to determine what could be done in the fight against ill health were also the ones who led the debate over what should be done in that struggle . This is a very different situation from what we have today where the two tasks tend most often to be estranged (Loughlin 28).
This disagreement is basically the stem of all debates in the field of medical ethics. On one hand we have the ever improving technology which pushes the boundaries of what doctors are capable of doing and on the other hand we have the question of what should be done in certain situation. Just because we can transplant organs from one person to another, keep them alive with machines, and use genetic engineering to determine the type of child a person will have, does not mean we should actually resort to such measures.
These sorts of questions are made more difficult by the current separation in medicine of technical skills and philosophical education. Doctors today are, by training, more technicians than philosophers which is not inherently a bad thing, considering how much technical skill is required for modern medicine. At the same time, all of that skill must be tempered by wisdom and a strong understanding of both the general philosophical and specific ethical issues involved in the various aspects of their work (30).
This is where the importance of studying the history of healthcare ethics comes in. Whether working directly with patients or doing basic research, doctors are capable of doing good and evil. The further medicine develops the more extreme the possible good and evil can become. We all have a stake in what they do, and this means that we should all study ethics in healthcare, not only the advancing medical technology, but also the proper responsibilities that doctors have towards patients.