Normative Methods in Healthcare Ethics Essay (Critical Writing)

Introduction

Ethics are simply concerned in distinguishing what is right or wrong, good or bad to the society. Several theories were developed to explain this but in one way or another, they differed from each other because some considered the morality of an action while others considered the consequences of an action. Deontological theories, normative and utilitarian theory are some of the ethical theories Jeremy and Daniel clearly explain some of these theories in their book and their relevant contributions to medical ethics as discussed below. Jonsen on the other hand indirectly applies these theories but he mainly focuses on normative ethics which he directly and openly discusses as we shall later in this article

According to Jeremy Daniel deontological theories, also known as Kantian theories judge the rightness and wrongness of an action based on its adherence to the rules that are to be followed¹. In other words, if a person completely adheres to the rules of a certain discipline then his actions are right, for instance, if a doctor tells a patient in a critical condition that he is not likely to survive and that there is no hope, he may be considered as a moral person because he has adhered to the rule of sharing every relevant information with patients. Jonsen also indirectly applies Deontological ethics when he introduces us to the modern medical ethics which suggests that some actions are wrong for instance lying to a patient to convince him to do the right thing. Modern ethics recommend that doctors tell their patients the whole truth and let the patients decide from the advice given to them by the medical specialists.

On the other hand, the Utilitarian theory demands that a right and moral action is one that produces more pleasure over pain². Pleasure in the medical involves healing of hence if any action leads to the healing of the patient then it is ethically right according to Utilitarians. In another word, the outcome of an action determines whether an action is right or wrong rather than considering whether the action itself is right or wrong. For instance, if a doctor has to lie to the patient to convince her to continue taking her medication then lying in this situation is right and good.

Also, it considers the number of people involved in that an action should produce more pleasure over pain to the majority of the population and not the minority. In other words, an action is considered right if it produces more happiness to most of the people that it affects. Medical ethics tend to differ with this although not in all situations. As we shall see later in this article the medical code of ethics demands that the doctor should share with the patient all relevant information about the disease and the form of treatment that he requires. They should not consider the consequences of them telling the truth but still, they should tell the patients in the right manner ensuring that the patients don’t get emotionally affected by the truth and by so doing they will be doing the right thing as normative ethics suggest.

Normative ethics

Normative ethics are concerned with what ‘we ought to do’. One should ask himself questions like ‘is it right to do this?’ Most disciplines have extensively adopted normative but this does not imply that normative ethics are more important than the others. The main challenge in normative ethics has been how to determine what is right and what is wrong also, differentiating the good from the bad has been a challenge because different disciplines, cultures, and generations value things differently and as you know one man’s meat is another man’s poison.

Normative ethics falls under different philosophical fields, e.g. metaethics and descriptive ethics both of which try to define what is right and what is not but from different points of view. According to Jeremy and Daniel (in their book ‘Methods in Medical Ethics’), metaethics tend to ask, “What does right mean? And what does ought mean?”³. Descriptive ethics, on the other hand, does not directly consider what is right or what people ought to do in certain situations. it considers what society defines as right or wrong. Jeremy and Daniel quoted that descriptive ethics tend to ask, “How do people think they ought to act in a particular situation?”⁴.

Normative medical ethics were also developed considering their conformity with common morality and principles. Common morality, in this case, refers to what different cultures consider as right or wrong while principles form the basis of morality. Different cultures have different principles hence the diversity in them. Scholars argued that if the medical issues were formulated by the general principles of several cultures then they would be accepted and applicable in the society.

However, the main challenge about this method was, there was no clear solution for a situation where principles from different cultures contradict each other. It was suggested that one should prevail over the other but still determining the stronger principle was still a challenge because different people value different things differently. This problem led to the adoption of applied ethics which also faced a lot of challenges

Interdisciplinary approach in the development of medical ethics

The authors of the two books agreed that medical ethics were developed by people from different disciplines who sat together and gave their normative views of medical ethics. Let’s start with Jeremy and Daniel who compares ethics in the medical profession with a bird described in a poem by Wallace Stevens, “Thirteen ways of looking at a blackbird”⁵. The poet never says what a blackbird is, but in every stanza, he talks about both the bird and the viewer, he explains how the viewer looks at the bird from multiple perspectives and by this, the reader gets an advantage of having a wider view of how complex the bird is. The same case applies to medical ethics.

There is no single discipline that can solely be used in formulating medical ethics starting from philosophy, anthropology, theology, sociology, etc. Jeremy and Daniel explained this in simpler terms as quoted below. The blackbird, in this case, represents medical ethics and the different perspectives represent the many disciplines (philosophy, anthropology, theology, sociology, etc.) that were used in developing medical ethics. Jeremy and Daniel further explain how different disciplines ask different ethical questions and view a single action from different points. This helps one to have a deeper and richer understanding of an ethical question and hence one can come up with a better solution/ answer⁶.

In a nutshell, Jeremy and Daniel recommend that medical ethics be considered as a field of study, which requires the knowledge of different disciplines that use different methods in looking at and solving ethical issues. (“One field, many disciplines, many methods”⁷). This idea was applied in the 1960s in the development of bioethics.

Jonsen, on the other hand, talks about the many conferences that were held in the 1960s starting with the one that was held in Dartmouth College whose main concern was normative ethics in the medical profession and the different opinions of specialists in different disciplines. In 1966 a conference was held in Portland (Reed College in Portland) and it was called “The of Sanctity of Life” was the next conference that developed a major shift in the adoption of bioethics. Specialists of almost all disciplines were present at this meeting for instance St. John Stevens was a British member of parliament and a lawyer by profession, Edward Shils, a sociologist, Paul Ramsey who was a theologian and a professor of Anesthesia, among others.

The Philosophers, Lawyer, and Theologists were invited to offer their expertise about scholarly ethics and how they can be integrated in bioethics. The major issues that formed the center of discussion were, “the morality of abortion, medical research involving human objects and the Medawar on eugenics“⁸.

The philosophers that were present presented Bertrand Russell’s philosophical way of reasoning. The inductive and deductive reasoning, in other words, they argued out from simplified to.complicated ethical issues and from complicated to simplified ones. The meeting was concluded by a remark by Professor Kaplan. He suggested that all moral judgments in the medical field must be by several principles the main one being the “principle of moral autonomy”, he continued and quoted that all doctors must commit themselves to respecting the moral liberty of other agents as well.

Development of the medical code of ethics

In the mid-eighteenth century, physicians were perceived as selfish, quarrelsome and dangerous. They were accused of doing more harm to the already sick people. According to Jonsen they were and framed for poisoning and butchering innocent sick people⁹.With time the medical profession improved and by mid-19th-century medical education was an organized profession and all students were supposed to be conversant with the “medical code of ethics”, also before pursuing their career they were supposed to acquire a regulated license.

Most of these measures were taken to stigmatize quackery and expose all forms of nostrums. The regulatory body that was responsible for all these changes was the AMA (American Medical Association) and it formulated a code of Ethics which was named after it (AMA principles of Medical Ethics)¹⁰.Jonsen in his book explains how in 1948 the public had already positively changed their perception towards doctors as he states how Dr. Ernest entered a medical profession that was by the public in a very high esteem this is because doctors had adopted the well-defined code of ethics that were accepted by the society. Jonsen insist that ethics brought respect and unity in the medical field¹¹.

The AMA codes of ethics were according to the economic, social and political status of that time transparent and clear to all. Most scholars who wrote articles at those times described them as ethics that lacked moral perplexity. This was until the early 70s when an unidentified author wrote and commented about some changes which were supposed to be made in the medical field. The changes in the “Traditional Western Ethics”¹², as the author referred to them as were to cope with the misgivings that were brought about by the new inventions and the exponential population growth. This was marked as the beginning of the introduction of bioethics in the medical profession.

Jonsen also briefly comments on the development of medical ethics in other traditional cultures where the people who cured people were considered as powerful and intelligent and their purpose was to make sure that “the law and order of nature” is maintained in the society. He explains that the traditional healers were not only supposed to cure people but they were supposed to cure them with good and right medicine which should agree with the customs, rules, and beliefs of the society¹³.

Jeremy and Daniel’s book also talk about virtues, codes, and professionalism in the medical field. They argue out that eastern and western medical ethics were developed from some societal codes and virtues that helped in solving ethical issues. In other words, medical ethical questions were argued out from how they differed or conformed with the codes and virtues of the society¹⁴. In other words, they were supposed to agree with the common morality as discussed above.

We have already seen several sources of normative medical ethics e.g. the AMA, traditional customs, common morality, etc. We will now look at another source that contributed to the development of medical ethics was the ‘social ethics’. Physicians had to show their importance to the society and win the public trust. This was during the middle age when medicine was declared as a discipline. It is during this time when universities, colleges, and guilds were being established.

From medical ethics to bioethics

Bioethics were adopted in the 1960s after several conferences were held by specialists from different disciplines from all over the world. The conference that impacted most significantly to this change was held in Dartmouth College (New Hampshire) and it was called “Great Issues of Conscience in Modern Medicine”¹⁵.

The specialists discussed some of the issues that were brought by the recent advancements of technology that affected the lives of humans e.g. the effects of ionizing radiation, water, and air pollution, etc. The medical field had also advanced people were cured from diseases that used to claim a lot of lives in other words, the death rate in almost all parts of the world was significantly reduced but the birth rate was not affected. This resulted to exponential population growth.

The new technology also helped in preventing the death of children with genetic defects and the old aged. This challenged the newly adopted bioethics and some questions about normative ethics. The questions that were raised were “Is it right to prevent the death of an ailing person or that of a child with genetic defects and they won’t enjoy any pleasure or profits of living?” this according to Rene Dubos was not a question for doctors to answer but for the society as a whole. He said that the duty of physicians was to save and prolong life but not to redefine ethics that affect their profession. The purpose of doctors is to air ethical problems to the society and the society, which comprises all disciplines, is to find solutions to the issues raised¹⁶.

Jeremy and Daniel briefly talk about bioethics which they refer to as postmodern ethics. He gives an example which agrees with Rene Dubos recommendations, discussed above. They refer to normative bioethics as a game in which everyone in the society is a real player and the societal moral norms are the rules of the game¹⁷.

Back to Johnson’s book, In late 1967 (the following year after Rene Dubos proposal) Dr. Barnard Christiaan in South Africa performed the first heart transplant and this raised more issues which specialists tried to argue out from an ethical point of view. They wanted a clear reasoning that would help doctors draw a clear line of ‘who to doctors should save and who they shouldn’t’. The complications, inconveniences, harm, and disadvantages that the patients suffered after being prevented from dying by doctors were no longer viewed from a professional or a technical point of view. They were viewed as ethical problems/ issues that required acute discussion, evaluation, and reflection.

The conferences resulted to establishment of research institutions that were mainly concerned about ethics in the medical profession. Three institutions were established in the early 1970s i.e. “The Hastings Center, The Kennedy Institute and The Society for Health and Human values”¹⁸. These institutions addressed the ethical issues from a multidisciplinary angle and conducted multiple types of research on modern bioethics.

Jeremy and Daniel’s work explains how medical ethics were developed on a religious and theological basis. Theologists advocated for medical ethics that were by religious norms, for instance, they believe that God the creator is the only one who should perform the role of creation. Cloning and all the new technologies that assisted reproduction were discovered by researchers were greatly opposed by Theologists who argued out that these practices were blasphemous and should not be practiced¹⁹.

Although they did not quote this but in my opinion, the issue of heart transplant in Jonsen’s book would be treated in the same manner by Theologists. They also believe that interfering with God’s natural creation would bring an Imbalance in nature and as a result species including humans would be put at risk of endangerment. Johnson’s work also agrees with this in that he quotes how traditional medicine men from different cultures were not only supposed to cure people but they were supposed to cure them in the right manner and by so doing there would be no imbalance in nature.

Conclusion

We have seen the two books reveal to us how medical ethics were developed physicians and other specialists from other disciplines e.g. theology, sociology, law, philosophy, etc, and they all mainly argued out from a normative point of view. The authors of the two books also present to us some historical evidence of how ethics in the medical field were either rejected or accepted by the society this was revealed by the way physicians were held, either in a low or a high esteem, in the society. In other words, every time physicians adopted ethics that were acceptable in the society they were held in high esteem and vice versa. Lastly, we have seen how ethics were mainly developed from a normative base but this does not mean that the other theories were not applied, the truth is they were also important but they contributed very little compared to normative ethics.

References

Albert, Jonsen,” Great issues of Conscience: Medical Ethics Before Bioethics”, 1998.

Jeremy, Sugarman. And Daniel. “Methods in medical ethics” 2010.

Footnotes

1. by Jeremy, Sugarman. and Daniel. “Methods in medical ethics” 2010, p 44.
2. Jeremy, Sugarman. and Daniel. p 43.
3. Jeremy, Sugarman. and Daniel. p 4.
4. Jeremy, Sugarman. and Daniel. “Methods in medical ethics” 2010, p 4.
5. Jeremy, Sugarman. and Daniel. p 4-5.
6. Jeremy, Sugarman. and Daniel. p 5.
7. Jeremy, Sugarman. and Daniel. p 6.
8. Albert, Jonsen page 18.
9. Albert, Jonsen,” Great issues of Conscience: Medical Ethics Before Bioethics”, 1998, p 4.
10. Albert, Jonsen. page 4-5.
11. Albert, Jonsen page 5.
12. Albert, Jonsen page 6.
13. Albert, Jonsen page 6.
14. Jeremy and Daniel page 91.
15. Albert, Jonsen page 13.
16. Albert, Jonsen page 14.
17. Jeremy and Daniel page 98.
18. Albert, Jonsen page 20.
19. Jeremy and Daniel page 73.