Medical ethics is defined as a system of moral principles that apply values to the practice of clinical medicine and in scientific research. Medical ethics is based on a set of values that professionals can refer to in the case of any confusion or conflict. These values include non-maleficence, respect for autonomy, justice, and beneficence1. These modern medical ethics four fundamental values were formed through crucial events in history. Non-maleficence is the earliest that historians can trace.
Non-maleficence means not harming or causing the least harm possible to obtain a favorable outcome1. Often considered the primary consideration for patients, the roots of non-maleficence can be traced to Hippocrates around 460 BC.
Hippocrates is believed to have made the earliest recorded statement regarding non-maleficence in an epidemiological book titled Epidemics I, “Declare the past, diagnose the present, foretell the future. As to diseases, make a habit of two things – to help and to not harm. The art has three factors, the disease, the patient, the physician. The physician is the servant of art. The patient must cooperate with the physician in combatting the disease.”3.
When Hippocrates stated “to help and not harm”, it initially was met with criticism as a physician’s primary purpose was to treat illness. However, other physician’s after seeing so many of their colleagues’ incompetence combined with the fact that many treatments did more harm than good, eventually came to embrace it.
The Hippocratic teachings gave all future physicians a basis to build their ethical framework. Aelius Galen, a Greek physician from 129 to 200 AD, preserved the Hippocratic teachings and was considered one of the first physicians to expand on them4.
When the Middle Ages came (approximately 400-1500 AD), the west was dominated by the Roman Catholic church and medical progress was considered stagnant and Hippocratic teaching was largely absent. In the 9th century, physician Ishaq ibn ‘Ali al-Ruhawi published his work, Practical Ethics of the Physicia5. Like the Christian church this treatise based much of its medical ethics on religion, in this case, Islam. However, unlike the Christian practices, al-Ruhawi’s version often cited Hippocrates, and many other Greek and Islamic philosophers.
The continued passing of the knowledge of non-maleficence through the Hippocratic teachings eventually led to the first modern medical code. Published in England in 1803, Thomas Percival’s book Medical Ethics, included non-maleficence as one of the Hippocratic quoted values6.
Dr. Percival’s ethics work was fiercely debated and not considered popular among the British. When United States was developing a medical community of its own, and Dr. Percival’s codes of ethics readily spread its influence. America worked to create its medical code of ethics, and in 1847 Dr. Isaac Hayes presented a draft of ethics to the National Medical Association. Dr. Hayes was forthright in his presentation as he confessed the draft of ethics was framed on Dr. Percival’s medical ethics works. The proposed ethics included the Hippocratic ethos of “do no harm” in the form of non-maleficence.
The National Medical Association that adopted those medical ethical guidelines eventual became the American Medical Association that we currently know. Professional medical ethicists consider non-maleficence one of four principle values.
Respect for a patient’s autonomy is a newer principle in medical ethics. The principle of autonomy10 is that a patient must be well informed of their illness and has the right to self-determine their treatment, including refusing treatment altogether.
Traditional Hippocratic teachings taught that a physician must always do whatever is in their power to treat the patient’s illness. As quoted earlier in Hippocrates Epidemics I writings: “The patient must cooperate with the physician in combatting the disease.”3. In other words, the physician’s treatment plan was considered absolute and the patient will not question it.
This type of expectation was common throughout history and not challenged until the 20th century in 1949 by Professor Joseph Fletcher in a lecture at Harvard University. Professor Fletcher discussed all the traditional medical ethics however he presented a new idea that was considered revolutionary; he asserted that patients had the basic right to determine what should be done with their medical care7. Physicians nor the church held authority over the patients’ mind or body.
This suggested move in authority from the physician to the patient was crucial in the forming of modern bioethics. Some 20 years later, bioethics was designed around the premise of patient autonomy. But one more significant event was pivotal in setting patient autonomy as a vital role in ethics.
In the United States from 1932 to 1972, researchers enrolled African Americans infected with syphilis in a bogus treatment program that gave the men placebos which led to numerous infections and deaths8. These men were all Tuskegee airmen stationed in Alabama. During the 1960s, a few doctors discovered the study and openly criticized it. It was not until a newspaper, the Washington Star, published one of the doctors’ concerns about the study.
The Washington Stars story made national news and led to congressional hearings that led to public outcry that finally ended this highly unethical experiment. The high-profile scandal led to the establishment of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research8. This commission recommended new regulations to the government that would protect the rights and welfare of research patients. These regulations were designed with respect for patient autonomy.
Justice, when referring to medical ethics, means that all patients have an equal right to the same level of treatment11. The medical ethic of justice is also seen as the societal burden of equitable distribution of health resources to all people. Unlike autonomy and non-maleficence, the Hippocratic texts do not address a duty to serve all people that are ill3.
Written by Scribonius Largus around 40 AD, the first text that alludes to equal treatment for all was and is entitled Compositiones: “…the recognition that all humans, of every nature and condition, were equal in one universal commonwealth. The physician’s service to the sick must transcend human enmity.” 9. Scribonius was a military healer, and it may have only been referring to the treatment of soldiers. His thinking did display a greater openness than just providing healing to one social order.
In the medieval period in Europe, healing was widely taken over by the Roman Catholic Church. The Church encouraged treatment of the sick as a work of charity. St. John Chrysostom told his congregation “It matter not whether the sick on is Christian, Jew or Gentile, rich or poor, slave or free: it is his need that calls out to you.” 10. When the plague started ravaging Europe, Christians became well known for their devotion to the sick, no matter their social status.
In 1803, Thomas Percival’s book Medical Ethics was again a significant turning point for it was the first modern text to advocate for equal medical treatment of the different social classes. For the first time, multiple physicians shared the care of patients, no matter their social status.
In the 1970s, the establishment of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research due to the Tuskegee Airmen scandal also led to the creation of the medical ethic of Justice.
Some scholars assert beneficence to be the primary principle of medical ethics. While non-maleficence prescribes “do no harm”, beneficence addresses the treatment of the patient’s health whereas the physician must serve the best interest of the patient when healing their illness or simply put, to do good for the patient12.
From the formation of the Hippocratic teachings through to modern medicine, the basic premise for beneficence is to heal the patient of their ill. It was not until Thomas Percival’s book Medical Ethicsthat physicians were told to advocate what is best for the patient.
Despite the American Medical Association adopting Thomas Percival’s ethical model in the late 1800s, the concept of beneficence was not enforced in the United States until the Tuskegee Airman scandal. The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research solidified beneficence where the patient’s treatment must serve the patients best interest.
The medical ethic values of non-maleficence, the respect for autonomy, justice and beneficence were formed through crucial events in history. Though the Tuskegee Airman scandal may have been the key point for most of the current four primary values of medical ethics, the constant evaluation of medical philosophies through history was necessary to lead to the current medical code of ethics.
Works Cited
- Beauchamp, J. Principles of Biomedical Ethics. Oxford University Press, 2012. P. 52
- Jonsen, Albert R. A Short History of Medical Ethics. Oxford University Press, 2008. p. 2
- Jonsen, Albert R. A Short History of Medical Ethics. Oxford University Press, 2008. pp. 10-11
- Jonsen, Albert R. A Short History of Medical Ethics. Oxford University Press, 2008. pp. 19-20
- Jonsen, Albert R. A Short History of Medical Ethics. Oxford University Press, 2008. pp. 58-60
- Jonsen, Albert R. A Short History of Medical Ethics. Oxford University Press, 2008. pp. 94-95
- Jonsen, Albert R. A Short History of Medical Ethics. Oxford University Press, 2008. pp. 108-109, 117
- Jonsen, Albert R. A Short History of Medical Ethics. Oxford University Press, 2008. pp. 9-10
- Jonsen, Albert R. A Short History of Medical Ethics. Oxford University Press, 2008. p. 14
- Beauchamp, J. Principles of Biomedical Ethics. Oxford University Press, 2012. P. 22
- Beauchamp, J. Principles of Biomedical Ethics. Oxford University Press, 2012. P. 44
- Beauchamp, J. Principles of Biomedical Ethics. Oxford University Press, 2012. P. 43
Other Work used for Reference
“Principles of Bioethics.” Chicano Movement Geography, Thomas R. McCormick, 2013, depts.washington.edu/bioethx/tools/princpl.html.