The New Challenges for Medical Ethics

*Liliana Lorettu, Jocelyn Aubut and Rosagemma Ciliberti*

### **Abstract**

The evolution of medicine confronts healthcare professionals with new ethical challenges. Elements such as professional secrecy, patient benefit, justice in the distribution of resources are put in crisis by the evolution of medical procedures. Today, doctors must make life-and-death decisions about many patients. As the resources are not enough for all patients, the 'first-come, first-served' criterion crumbles under the weight of the overwhelming demand for treatment. Consequently, they can no longer make treatment decisions based only on proportionality and clinical appropriateness criteria. They must take into account the availability of resources and prioritise patients with 'the longer life expectancy'. This amounts to saying 'the weakest will die' ... with the doctors' consent. While the guidelines issued by scientific societies may well protect doctors from lawsuits, the choice of who to treat and who to let die is left to the conscience of the individual doctor; and it is a choice sharply clashing with the Hippocratic oath and with professional and personal ethics. This and others are a real ethical problem.

**Keywords:** medical ethics, professional responsibility, availability of resources

#### **1. Introduction**

Biomedical ethics has made giant strides over the past decades and has come to be recognised as integral to medical education. This has encouraged the growing inclusion of the teaching of medical ethics, together with that of the human sciences, in the syllabi of medical and nursing schools. In the 1980s, increased awareness of ethical issues shone a light on some excesses of medical research and medical paternalism which conflicted with ethical principles. The 1990s saw the establishment of the first medical ethics committees in hospitals, overseeing both research and clinical practice. Since the 2000s, the various bodies regulating the doctors' right to practice have issued regulations, guidelines and recommendations laying down formal ethical rules for medical practice, together with a system of penalties for infringement of these rules.

Many social and cultural factors have contributed to the increase in ethical concerns. The increase in individual civil liberties, codified in various Charters of Citizens' Rights, has fuelled a growing drive to claim new rights in previously unexplored areas. The development of biomedical technologies has created new frontiers, such as the attempt to shape one's own medical fate, as in the case of the actress Angelina Jolie, who chose to undergo preventive double mastectomy and subsequent ovariectomy because she carried a gene that greatly increased (over 80%) her risk of developing an aggressive and often fatal type of breast cancer, or the decision of a

British manager to have his prostate removed for the same reason. In the meantime, the constant budget cuts have increased the need to make very complex choices.

Recently, the Covid-19 pandemic has confronted us with specific ethical dilemmas, in particular the choice about who to treat or not to treat in a health emergency with scarce resources.

The growing ethical concerns have highlighted the fact that doctors only receive very basic training in medical ethics during their studies and practical training. Some studies even show that the awareness of ethical issues of students and trainees decreases as they advance in their studies [1, 2].

Most doctors trust their ethical judgement and believe that their decisions are morally sound. Yet most doctors lack adequate training and theoretical knowledge of ethical issues to support their beliefs and choices in a manner that stands up to scrutiny. The ethical judgement of most doctors is based on their professional life experience, personal opinions, beliefs and values, but few know the theoretical foundations of biomedical ethics and moral decision-making.

The first part of this paper outlines the key theoretical concepts framing ethical decision-making by physicians. Next, the principles governing the ethical decisionmaking process are presented. This is important because ethics is not only about the medical decision, but also about the process for reaching that decision. Certain issues in the application of ethical principles and the challenges brought by current events to medical ethics are also discussed.

### **2. Historical overview and remarks on the relationship between medical ethics and bioethics**

The birth of bioethics as understood today is closely linked to the giant strides made by the biomedical sciences and technologies (most notably molecular biology and genetic engineering) around the 1970s.

The gradual unlocking of the mechanisms of life, coupled with the possibility of manipulating and modifying living beings, enabled a number of procedures that gave rise to widespread ethical concerns: medically assisted reproduction, tissue and organ transplantation, genetic intervention, the possibility of artificial life independent of 'natural' life, euthanasia, cloning, etc.

The word *Bio-Ethik* was coined by German Protestant pastor and ethicist Fritz Jahr, who used the term to propose a new bioethical imperative that extended to all living beings Kant's categorical imperative of respect for all persons [3, 4].

However, the current meaning of bioethics can be ascribed to American oncologist Van Rensselaer Potter, who used this term in a paper entitled *Bioethics: the science of survival* [5] and later in his best-known work *Bioethics: a bridge to the future* [6].

According to Potter, building an ethic based on scientific knowledge is necessary to ensure the very survival of *Homo sapiens*, which could be threatened if research were allowed to proceed unchecked and unfettered. Potter rejected merely speculative knowledge and stressed the need to connect ethical values, traditionally confined to the realm of the humanities, with biological facts and thus build a 'bridge to the future'.

Potter himself defined bioethics as the 'knowledge of how to use knowledge', to highlight the distinctive nature of this discipline as a dialogical meeting point between the natural sciences, the social sciences and philosophy.

In his subsequent book, entitled *Global Bioethics*, Potter made the by now wellestablished subdivision of bioethics into three branches: medical ethics, environmental ethics and animal ethics [7].

**309**

*The New Challenges for Medical Ethics DOI: http://dx.doi.org/10.5772/intechopen.94833*

bioethics proper.

thing we can do?

between science and ethics.

avoidance of injury;

benefits;

relationship between ethics and science.

time the following standards for human experiments:

1972 [12].

It is interesting to note that originally, the scope of bioethics was not restricted to medical practice, even though in subsequent years this came to be considered its main, if not exclusive, area of concern. Indeed, differently from Potter's definition of bioethics (later followed by Jonas in his work *The Responsibility Principle* [8]) the term has mostly been applied in the narrower sense given to it by Dutch obstetrician Andre E. Hellegers, co-founder of the Kennedy Institute, who considered bioethics as ethics applied to the biomedical sciences [9]. This narrowing of the scope of bioethics from its original reflection on the ethical problems relating to life, '*bios*' in all its complexity, is partly due to the fact that the two centres where bioethics research and teaching were first developed (the Kennedy Institute in Washington and the Hastings Center in New York) focused on medical issues, specifically, on medically assisted reproduction. This meant that issues such as the treatment of animals or environmental risks were not considered to fall within the scope of

The close links between the different facets of bioethics and the high complexity of the problems addressed require constant cross-disciplinary dialogue among scientists and scholars from a range of disciplines such as philosophy, law, econom-

The interdisciplinary nature of bioethics is also in evidence in the current definition of this discipline, contained in the 2nd edition of the Encyclopedia of bioethics: '*Bioethics is the systematic study of the moral dimensions - including moral vision, decisions, conduct, and policies - of the life sciences and health care, employing a variety* 

The relationship between ethics and science is certainly at the heart of philosophical reflection and may be summed up in one question: should we do every-

In the United States, the debate on ethical issues had already started long before the breakthroughs in genetics: it was prompted by news of gross abuses committed in several clinical trials, namely at the Jewish Chronic Disease Hospital in Brooklyn, the Willowbrook State Hospital in New York and in the famous 'Tuskegee Study of Untreated Syphilis in the Negro Male' which began in 1932 and continued until

However, the historical roots of bioethics and, in particular, of medical ethics, can be traced further back in time by a deeper examination of the relationship

The atrocities committed in the experiments on concentration camp prisoners in Nazi Germany dramatically revealed, well before the later events that prompted the appearance of the term 'bioethics' in the literature, the need to investigate the

The Nuremberg Code was the first document to enshrine in specific rules the ethical principles that govern research on human subject. The Code, which although it never attained legal value has a universal moral value, established for the first

• The voluntary consent of the human subject is absolutely essential: this means that the person involved must be given detailed prior information about the

• the experiment must be justified in terms of necessity, anticipated results and

• the risks of the experiment must be carefully weighed against the expected

nature, purpose, duration, means and risks of the experiment;

ics, sociology, ethology, psychology and anthropology [10].

*of ethical methodologies in an interdisciplinary setting*' [11].

#### *The New Challenges for Medical Ethics DOI: http://dx.doi.org/10.5772/intechopen.94833*

*Bioethics in Medicine and Society*

with scarce resources.

decreases as they advance in their studies [1, 2].

events to medical ethics are also discussed.

and genetic engineering) around the 1970s.

independent of 'natural' life, euthanasia, cloning, etc.

**ethics and bioethics**

foundations of biomedical ethics and moral decision-making.

British manager to have his prostate removed for the same reason. In the meantime, the constant budget cuts have increased the need to make very complex choices. Recently, the Covid-19 pandemic has confronted us with specific ethical dilemmas, in particular the choice about who to treat or not to treat in a health emergency

The growing ethical concerns have highlighted the fact that doctors only receive very basic training in medical ethics during their studies and practical training. Some studies even show that the awareness of ethical issues of students and trainees

Most doctors trust their ethical judgement and believe that their decisions are morally sound. Yet most doctors lack adequate training and theoretical knowledge of ethical issues to support their beliefs and choices in a manner that stands up to scrutiny. The ethical judgement of most doctors is based on their professional life experience, personal opinions, beliefs and values, but few know the theoretical

The first part of this paper outlines the key theoretical concepts framing ethical decision-making by physicians. Next, the principles governing the ethical decisionmaking process are presented. This is important because ethics is not only about the medical decision, but also about the process for reaching that decision. Certain issues in the application of ethical principles and the challenges brought by current

**2. Historical overview and remarks on the relationship between medical** 

The birth of bioethics as understood today is closely linked to the giant strides made by the biomedical sciences and technologies (most notably molecular biology

The gradual unlocking of the mechanisms of life, coupled with the possibility of manipulating and modifying living beings, enabled a number of procedures that gave rise to widespread ethical concerns: medically assisted reproduction, tissue and organ transplantation, genetic intervention, the possibility of artificial life

The word *Bio-Ethik* was coined by German Protestant pastor and ethicist Fritz Jahr, who used the term to propose a new bioethical imperative that extended to all

According to Potter, building an ethic based on scientific knowledge is necessary to ensure the very survival of *Homo sapiens*, which could be threatened if research were allowed to proceed unchecked and unfettered. Potter rejected merely speculative knowledge and stressed the need to connect ethical values, traditionally confined to the realm of the humanities, with biological facts and thus build a

Potter himself defined bioethics as the 'knowledge of how to use knowledge', to highlight the distinctive nature of this discipline as a dialogical meeting point

In his subsequent book, entitled *Global Bioethics*, Potter made the by now wellestablished subdivision of bioethics into three branches: medical ethics, environ-

between the natural sciences, the social sciences and philosophy.

living beings Kant's categorical imperative of respect for all persons [3, 4]. However, the current meaning of bioethics can be ascribed to American oncologist Van Rensselaer Potter, who used this term in a paper entitled *Bioethics: the science of survival* [5] and later in his best-known work *Bioethics: a bridge to the* 

**308**

*future* [6].

'bridge to the future'.

mental ethics and animal ethics [7].

It is interesting to note that originally, the scope of bioethics was not restricted to medical practice, even though in subsequent years this came to be considered its main, if not exclusive, area of concern. Indeed, differently from Potter's definition of bioethics (later followed by Jonas in his work *The Responsibility Principle* [8]) the term has mostly been applied in the narrower sense given to it by Dutch obstetrician Andre E. Hellegers, co-founder of the Kennedy Institute, who considered bioethics as ethics applied to the biomedical sciences [9]. This narrowing of the scope of bioethics from its original reflection on the ethical problems relating to life, '*bios*' in all its complexity, is partly due to the fact that the two centres where bioethics research and teaching were first developed (the Kennedy Institute in Washington and the Hastings Center in New York) focused on medical issues, specifically, on medically assisted reproduction. This meant that issues such as the treatment of animals or environmental risks were not considered to fall within the scope of bioethics proper.

The close links between the different facets of bioethics and the high complexity of the problems addressed require constant cross-disciplinary dialogue among scientists and scholars from a range of disciplines such as philosophy, law, economics, sociology, ethology, psychology and anthropology [10].

The interdisciplinary nature of bioethics is also in evidence in the current definition of this discipline, contained in the 2nd edition of the Encyclopedia of bioethics: '*Bioethics is the systematic study of the moral dimensions - including moral vision, decisions, conduct, and policies - of the life sciences and health care, employing a variety of ethical methodologies in an interdisciplinary setting*' [11].

The relationship between ethics and science is certainly at the heart of philosophical reflection and may be summed up in one question: should we do everything we can do?

In the United States, the debate on ethical issues had already started long before the breakthroughs in genetics: it was prompted by news of gross abuses committed in several clinical trials, namely at the Jewish Chronic Disease Hospital in Brooklyn, the Willowbrook State Hospital in New York and in the famous 'Tuskegee Study of Untreated Syphilis in the Negro Male' which began in 1932 and continued until 1972 [12].

However, the historical roots of bioethics and, in particular, of medical ethics, can be traced further back in time by a deeper examination of the relationship between science and ethics.

The atrocities committed in the experiments on concentration camp prisoners in Nazi Germany dramatically revealed, well before the later events that prompted the appearance of the term 'bioethics' in the literature, the need to investigate the relationship between ethics and science.

The Nuremberg Code was the first document to enshrine in specific rules the ethical principles that govern research on human subject. The Code, which although it never attained legal value has a universal moral value, established for the first time the following standards for human experiments:


Thus, the Nuremberg Code is a landmark document in the development of medical ethics, paving the way for a gradual and profound revision of the doctorpatient relationship in order to shed the traditional paternalistic approach in favour of the principles of consent, shared decision-making and therapeutic alliance.

Following the Nuremberg trial and the consequent drafting of the Nuremberg Code (1946), several international instruments on human rights were drafted, starting from the Universal Declaration of Human Rights (1948), which laid down the first legal principles of bioethics. The Declaration contains strong statements on the right to life and physical integrity, together with other fundamental civil and political freedoms. In so doing, it opened up a new legal and regulatory path for bioethics and inspired and influenced the subsequent development of international legislation.

The global and regional documents, charters, declarations and conventions that followed explicitly refer to the Universal Declaration of Human Rights as the foundation of their statutes and precepts, including the WMA Declaration of Geneva and the International Code of Medical Ethics of 1948 and the WMA Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects of 1964 (with its several subsequent amendments.

However, with regard to the aims of bioethics, it would be reductive and historically incorrect to limit its statutory, founding aims to the need to fix the ethical boundaries for the technical progress of science. As Mori [13] pointed out, what the Nuremberg trial itself so dramatically exposed is the need to set limits not to the technological advances of science but to the abuse of those advances. Thus, Mori reminds us that the core problem of bioethics is not to trace the boundaries of technological advancement, pitting science against ethics, but to identify the reasons that justify a specific moral judgement. Thus, as remarked by Schiavone [14], a crucial premise for any ethical approach to be legitimate and justified is that any critical reflection on scientific areas and disciplines should originate and develop within science itself and the scientific and technical advances achieved by it, instead of referring to a source of regulation outside science.

Far from being a system distinct from science and which attempts to stem its progress, bioethics aims to pursue critical and coherent reflection on human dignity, as an instrument of moral control (in the secular sense) over science in terms of its impact on human beings and the environment.

The subject matter of bioethics (which concerns itself with the sphere of '*bios*', i.e. living beings) is associated with the theme of the destiny of human beings, and thus is an emotionally charged topic, inevitably subject to strong pressures. Bioethics is constantly at risk of sliding from the role of neutral and unbiased observatory – to the extent that such a role can effectively be achieved and maintained – onto the dangerous terrain of ideology and its associated dogmatic views.

Returning to the question of the origins of bioethics, it should be noted that ethical reflection in medicine dates back to long before Potter's text. The Hippocratic oath is significant evidence of this. The oath, which evidently reflects the philosophy and culture of a time when the medical profession had a hieratic character, contains the seed bioethics in its principles of *non nocere* (i.e. 'do no harm' to the patient) and 'beneficence' as cornerstones of the doctor's activity.

**311**

**Figure 1.**

importantly, those of their patients.

*Main documents on medical ethics.*

The Western world has adopted this approach and has formulated codes of medical ethics and laws inspired by ethical principles to regulate the exercise of the medical profession. These sets of rules are regularly updated in response to cultural and ethical developments and to the growing demand for professional standards to safeguard not only the interests of medical professionals, but also, and most

In this regard, medical ethics and standards of professional conduct play a major role in the physician-patient relationship. This is the setting where protecting the patient's fundamental rights is crucial and where the risk that medical practice may infringe the individual's rights protected by the Constitution is highest. Indeed,

*The New Challenges for Medical Ethics DOI: http://dx.doi.org/10.5772/intechopen.94833* *Bioethics in Medicine and Society*

qualified;

legislation.

• the personnel conducting the experiment must be appropriately trained and

• it must be possible to bring the experiment to an end at any time on the initia-

The global and regional documents, charters, declarations and conventions that followed explicitly refer to the Universal Declaration of Human Rights as the foundation of their statutes and precepts, including the WMA Declaration of Geneva and the International Code of Medical Ethics of 1948 and the WMA Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects of

However, with regard to the aims of bioethics, it would be reductive and histori-

Far from being a system distinct from science and which attempts to stem its progress, bioethics aims to pursue critical and coherent reflection on human dignity, as an instrument of moral control (in the secular sense) over science in terms

The subject matter of bioethics (which concerns itself with the sphere of '*bios*', i.e. living beings) is associated with the theme of the destiny of human beings, and thus is an emotionally charged topic, inevitably subject to strong pressures. Bioethics is constantly at risk of sliding from the role of neutral and unbiased observatory – to the extent that such a role can effectively be achieved and maintained –

onto the dangerous terrain of ideology and its associated dogmatic views. Returning to the question of the origins of bioethics, it should be noted that ethical reflection in medicine dates back to long before Potter's text. The Hippocratic oath is significant evidence of this. The oath, which evidently reflects the philosophy and culture of a time when the medical profession had a hieratic character, contains the seed bioethics in its principles of *non nocere* (i.e. 'do no harm'

to the patient) and 'beneficence' as cornerstones of the doctor's activity.

cally incorrect to limit its statutory, founding aims to the need to fix the ethical boundaries for the technical progress of science. As Mori [13] pointed out, what the Nuremberg trial itself so dramatically exposed is the need to set limits not to the technological advances of science but to the abuse of those advances. Thus, Mori reminds us that the core problem of bioethics is not to trace the boundaries of technological advancement, pitting science against ethics, but to identify the reasons that justify a specific moral judgement. Thus, as remarked by Schiavone [14], a crucial premise for any ethical approach to be legitimate and justified is that any critical reflection on scientific areas and disciplines should originate and develop within science itself and the scientific and technical advances achieved by

it, instead of referring to a source of regulation outside science.

of its impact on human beings and the environment.

Thus, the Nuremberg Code is a landmark document in the development of medical ethics, paving the way for a gradual and profound revision of the doctorpatient relationship in order to shed the traditional paternalistic approach in favour of the principles of consent, shared decision-making and therapeutic alliance. Following the Nuremberg trial and the consequent drafting of the Nuremberg Code (1946), several international instruments on human rights were drafted, starting from the Universal Declaration of Human Rights (1948), which laid down the first legal principles of bioethics. The Declaration contains strong statements on the right to life and physical integrity, together with other fundamental civil and political freedoms. In so doing, it opened up a new legal and regulatory path for bioethics and inspired and influenced the subsequent development of international

• appropriate equipment and facilities must be used;

tive of either the human subject or the scientist.

1964 (with its several subsequent amendments.

**310**


#### **Figure 1.**

*Main documents on medical ethics.*

The Western world has adopted this approach and has formulated codes of medical ethics and laws inspired by ethical principles to regulate the exercise of the medical profession. These sets of rules are regularly updated in response to cultural and ethical developments and to the growing demand for professional standards to safeguard not only the interests of medical professionals, but also, and most importantly, those of their patients.

In this regard, medical ethics and standards of professional conduct play a major role in the physician-patient relationship. This is the setting where protecting the patient's fundamental rights is crucial and where the risk that medical practice may infringe the individual's rights protected by the Constitution is highest. Indeed,

since ancient times, the power imbalance inherent in the patient-provider relationship has required a framework of principles and rules specifying the physician's duties, in order to protect the patient (**Figure 1**).
