Since ancient times, medical practice has been concerned with ethical issues. But only since the last half of the twentieth century have the rapid advances in medicine given rise to so many ethical dilemmas. In matters of death and dying, the debate continues on such issues as physicians' honoring a patient's do-not-resuscitate order, withholding food and fluids, and withdrawing artificial respiration.
There are four basic tenets of bioethics: autonomy, beneficence, nonmaleficence, and justice. Autonomy refers to self-rule and self-determination. Beneficence is action that is in the best interest of the patient. Nonmaleficence means to do no harm. Justice is the practice of treating patients in comparable circumstances the same way, and also refers to equitable distribution of resources, risks, and costs. Although bioethics is subject to change and reinterpretation, medical practice continues to rely on these principles to guide the actions of physicians and other health care providers.
The Hippocratic Oath
The earliest document on medical ethics is generally attributed to Hippocrates (circa 460–370 BCE), known as the father of medicine. For more than 2,000 years, the Hippocratic Oath has been adopted by Western physicians as a code of ethics, defining their conduct in the discharge of their duties. In part, the oath states:
I will follow that method of treatment, which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious [harmful] and mischievous. I will give no deadly medicine to anyone if asked, nor suggest any such counsel.
Nonetheless, some scholars claim that the giving of "deadly medicine" did not refer to euthanasia. During the time of Hippocrates, helping a suffering person end his or her life was common practice. The oath might therefore have been more an admonition to the medical profession to avoid acting as an accomplice to murder, rather than to refrain from the practice of euthanasia.
Some physicians believe that literal interpretation of the oath is not necessary. It simply offers guidelines that allow for adaptation to modern-day situations. In fact, in 1948 the World Medical Association modified the Hippocratic Oath to call attention to the atrocities committed by Nazi physicians. Known as the Declaration of Geneva, the document reads in part:
I will practice medicine with conscience and dignity. The health and life of my patient will be my first consideration.… I will not permit consideration of race, religion, nationality, party politics, or social standing to intervene between my duty and my patient. I will maintain the utmost respect for human life from the time of its conception. Even under threat, I will not use my knowledge contrary to the laws of humanity.
The Physician's Role
Even in ancient times, as can be gleaned from the Hippocratic Oath, physicians believed they knew what was best for their patients. Patients relied on their doctors' ability and judgment, and usually did not question the treatments prescribed. Doctors were not even required to tell their patients the details of their illness, even if they were terminally ill.
Beginning in the 1960s many patients assumed a more active role in their medical care. The emphasis on preventive medicine encouraged people to take responsibility for their own health. Physicians were faced with a new breed of patients who wanted to be active participants in their health care. Patients also wanted to know more about modern technologies and procedures that were evolving in medicine. With this new health consciousness, physicians and hospitals assumed the responsibility for informing and educating patients, and increasingly were legally liable for failing to inform patients of the consequences of medical treatments and procedures.
To compound the complexity of the changing patient-physician relationship, modern technology, which could sometimes prolong life, was also prolonging death. Historically, physicians had been trained to prevent and combat death, rather than to deal with dying patients, communicate with the patient and the family about a terminal illness, prepare them for an imminent death, or respond to a patient requesting assisted suicide.
Until the late 1990s, medical education programs offered very little in the area of end-of-life care. Drs. J. Andrew Billings and Susan Block reported that a 1991 survey of medical school deans revealed that only 11 percent of schools offered a full-term course on death and dying ("Palliative Care in Undergraduate Medical Education," Journal of the American Medical Association, vol. 278, no. 9, September 3, 1997). About 52 percent offered death education as part of other required courses, while another 30 percent offered only one or two lectures as part of another course. In 1997, while some medical schools offered information on dealing with death as part of other required courses, only 5 of 126 medical schools in the United States offered a separate required course on death and dying.
This situation began to improve in the late 1990s. The Education for Physicians on End-of-Life Care (EPEC) Project, developed in 1998 by the American Medical Association (AMA), is an ambitious training program that aims to provide physicians with the knowledge they need to care for dying patients. The curriculum emphasizes development of skills and competence in the areas of communication, ethical decision making, palliative care, psychosocial issues, and pain and symptom management. The program became fully operational in 1999 and provides curricula to all leaders of medical societies, medical school deans, and major medical organizations. The EPEC Project was supported from 1996 to 2003 with funding from the Robert Wood Johnson Foundation. It is currently sponsored by Northwestern University Medical School in Chicago with a mission to educate all health care professionals on the essential clinical competencies in end-of-life care.
In addition to acquiring the training and skills to respond effectively to the needs of dying patients, end-of-life education programs encourage physicians and other health care providers to examine their own feelings, values, and beliefs about dying. By questioning and understanding deeply held beliefs, such as the perception of a patient's death as a professional failure, health care workers are less likely to feel conflicted or uncomfortable when caring for dying patients and their families.
Contemporary Ethical Guidelines for Physicians
Physicians are trained to save lives, not to let people die. Advanced medical technology, with respirators and parenteral nutrition (artificial feeding devices that provide nutrition to an otherwise unconscious patient), can prolong the process of dying. Dr. Ira Byock, in Dying Well: The Prospect for Growth at the End of Life (New York: G. P. Putnam's Sons, 1997), admitted:
A strong presumption throughout my medical education was that all seriously ill people required vigorous life-prolonging treatments, including those who were expected to die, even patients with advanced, chronic illness such as widespread cancer, end-stage congestive heart failure, and kidney or liver failure. It even extended to patients who saw death as a relief from the suffering caused by their illness.
The Council on Ethical and Judicial Affairs of the American Medical Association published guidelines for physicians dealing with patients in nonemergency situations ("Decisions Near the End of Life," Journal of the American Medical Association, vol. 267, no. 16, April 22, 1992). A summary of these guidelines follows:
- Following the principle of patient autonomy, physicians must respect the decision of a competent patient to forego life-sustaining treatment (any treatment that prolongs life without curing the conditions of the illness). Examples of life-sustaining treatment are mechanical respiration, dialysis, chemotherapy, antibiotics, and artificial nutrition and hydration.
- Medical ethics allows for the likelihood that withholding or withdrawing life-sustaining treatment per patient's request might result in death. Neither one is a harmful treatment but a foregoing of a treatment.
- Physicians must ease a patient's pain and suffering even if to do so may possibly hasten death.
- Physicians must not perform euthanasia or assist in suicide.
Another prominent professional medical organization, the American College of Physicians (ACP), revised its recommendations about end-of-life care in the fourth edition of its code of ethics, The American College of Physicians Ethics Manual (Philadelphia: ACP, 1998). The manual's guidelines for decision making near the end of life emphasize that capable and informed adults nearly always have the legal and ethical right to refuse treatment. They advise physicians to practice empathy, to compromise, and to negotiate with patients who wish to forego recommended treatment. The guidelines offer an approach to clinical ethical decision making that not only involves defining the problems and reviewing facts and uncertainties, but also considers the patient's emotional state, ethnicity, culture, and religious traditions.