Look what's happened to medical ethics: broader horizons, updated ideas, fresh language.

The health care scene is topsy-turvy.

Stem cell experts and other researchers fake results for fame and profit.

The once unassailable Hippocratic oath is under fire.

Body parts are for sale.

Few seem to understand the difference between what is legal and what is right.

In some executive offices and boardrooms, concern with compliance and confidentiality is more visible than the avowed mission of compassion and caring.

Clearly, traditional approaches to medical ethics and to ethics in general are history now, inadequate to the tasks of today, relevant only to past simplicity.

So, say farewell to medical ethics and moral philosophy. Welcome to the brave new world of 21st century health care ethics and moral intelligence.

Medical ethics is now just one dimension of three-dimensional 21st century health care ethics. Furthermore, changes in thinking about ethical aspects of health care issues reflect recent ideological contributions of modern day ethical theorists.

Organizational leaders responsible for ethics, such as the vice president for ethics and members of the hospital ethics committee, may or may not fully understand the impact of these changes on their work.

21st century health care ethics

The three dimensions of 21st century health care ethics are:

1. Traditional medical ethics

2. Medical bioethics 

3. Organizational ethics applied to health care

Traditional medical ethics includes familiar-sounding issues such as informed consent, privacy of personal medical information, social and economic distributive justice as it applies to federal and state health care policymaking and life-end issues such as living wills and euthanasia.

We should not assume familiarity even with these issues because many of them continually present us with new dilemmas. For example, living wills are now a welcome and well-accepted relief from the illusion that there are no fates worse than death.

In addition, palliative care and hospice placement are acceptable choices for the terminally ill. That is, at the request of the patient the goal of treatment can shift from fruitless pursuit of the impossible to calm acceptance and comfort, at least to the extent that those words have meaning in the context of dying.

Now comes the suggestion that carefully controlled assistance with dying gracefully should also be openly offered to those requesting that alternative. (1)

As is typical of any ethical dilemma, there are many views of this proposal. Some gaze aghast at the very idea, some say no because it would taint public confidence in doctors and nurses, and others say why not because it would only legalize a relatively common practice.

Medical bioethics includes the highly visible group of issues related to reproductive biology, such as stem cell research and human cloning. Also, gene therapy capability raises several issues, including whether or not a person's naturally occurring genes can be patented and become someone else's intellectual property. (2)

In some cases, traditional medical ethics issues and bioethics issues overlap. For example, the need for testing gene therapy products in humans prior to approval adds a new dimension to safeguarding the safety of human research subjects. (3)

Organizational ethics applied to health care encompasses a wide range of issues such as honesty in advertising, employee rights, women in the workplace, (4) extent of executive privilege, avoidance of conflict of interest and understanding the difference between compliance and ethical behavior. (5)

Full and honest consideration of such issues requires recognition and acceptance of the uniqueness of the health care business. That is, as stated by Hall, "Health care institutions are, in fact, business organizations, with most of the problems faced by corporate management in other fields. They differ, however, in that health care holds a special place among human needs." (6)

Ethics as moral intelligence

Chances are that what you think you know about ethics is now the history of ethics.

Traditional ethics, based on a variety of academic schools of thought, was an abstract pursuit of moral absolutes. Interest in ethics was confined primarily to university philosophy departments.

A good philosophical ethicist was one who could confound and confuse his colleagues with a measured mix of obfuscation, pontification and conflation of ideas. No single school of thought proved a sufficient basis for all ethical thinking, so circular discussions continued for centuries. That kind of other-worldly ethics was of little interest or usefulness to most people coping daily with practical economic and political realities. In those days, a synonym for ethics was moral philosophy.

Today, philosophy-based ethics is giving way to principles-based ethics. As expressed by health care ethics experts Tom Beauchamp and James Childress, "To the surprise of many philosophers in the last twenty years, often little is lost in practical moral decision making by dispensing with general moral theories. Rules and principles shared across these theories typically serve practical judgment more adequately (as starting points) than the theories." (7)

Beauchamp and Childress emphasize four key principles

1. Autonomy (self-determination)

2. Beneficence 

3. Non-malfeasance

4. Social and economic distributive justice

Moral intelligence is thoughtful application of objective but not absolute ethical principles to specific fact situations in order to predict possible long range effects of our actions on ourselves and others.

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An important component of principles-based ethics is the concept of prima facie ethical values. (8) Prima facie literally means on the face of the matter, without further examination. On the face of it, truth telling might appear to be an absolute value. But it is not. Consider the following example.

A woman asks a man, "Honey, how do you like my new hairdo?" The man's answer will not shake the foundations of deep philosophical conjecture nor does the moment carry the weight of a moral search for generalizable righteousness. This does not make the answer unimportant. The man's honest answer is, "The look is a mistake; it makes you look older."

The woman and her hairdresser disagree, so what good is done by serving the cause of absolute truth in this situation? Indeed, absolute truth cannot be served because in this situation, as in many difficult situations, there are two truths, a greater and a lesser. The lesser truth is the man's opinion of the hairdo. The greater truth is that at this moment the world consists of only two people and the man's answer will greatly affect the happiness of everyone in this small world, perhaps for a long time to come.

In this and similar situations, more good and less harm can result from flexible use of objective ethical values than by insisting on compulsive compliance with an absolute rule. So even truth telling is a prima facie ethical value--on the face of it one should tell the truth, but on further examination complexities of the situation suggest a more thoughtful response.

Moral intelligence requires use of the prima facie concept, but it also requires the discipline to remain true to the greater truth in a difficult situation. Without this discipline, principles-based ethics can deteriorate into moral relativism, a totally intuitive approach to ethical behavior that lacks both consistency and effectiveness.

Moral intelligence benefits the actor as well as the acted upon. For example, for a time in some managed care systems, physicians were not allowed to tell patients that they needed certain expensive diagnostic or treatment services. A modicum of moral intelligence might have prevented the use of such gag orders. The practice was short-lived, yet loss of confidence and trust generated by this and other ill-advised actions persists.

Rediscovering reasonable self-interest

Some never discover ethical behavior, which we are calling moral intelligence, beyond a childhood admonition to "be mindful of the needs of others."

This well-meaning parental attempt to encourage moral growth and development leaves the impression that moral behavior is synonymous with sacrifice. Some ethical theories and some religious traditions perpetuate that myth.

However, most ethical theories, including Aristotle's creation of Western virtue ethics, (9) take root in the human instinct to pursue reasonable self-interest. An excellent example of moral intelligence is the ability to distinguish between reasonable self-interest and greed.

Mike Singletary, all-pro middle linebacker of the 1985 Super Bowl champion Chicago Bears, once explained the standard of play sought by his defensive unit. In every game, the team's goals were no points scored, no passes completed, no yards gained and no first downs. Singletary commented, "We never met those goals, but keeping those goals in sight made us a pretty good defense."

To some extent, modern ethicists have made the same discovery. That is, unlike their predecessors and unlike today's militant punishment-oriented moralists, today's ethicists allow for human frailty

The expectation is not that we all be saints. Rather, the expectation is that we will exert reasonable effort to include moral intelligence as well as economic intelligence in our decision making process, most of the time.

Richard E. Thompson, MD, is author of Think Before You Believe: Modern Day Myths, Questionable Claims and Uncommon Sense, Xlibris, Philadelphia, 2004. He teaches ethics at Missouri State University. Springfield, Mo. and can be reached at [e-mail]

References

1. Quill TE, MD, and Meier, DE MD. "The big chill: Inserting the DEA into end of life care." NEJM 314(1):1-3 January 5, 2006.

2. Thompson RE, MD. "Does patenting genes change the meaning of life?" The Physician Executive, 29(3):40-2, May-June 2003.

3. Thompson RE, MD. "Are human research subjects safe enough?" The Physician Executive, 29(4):82-4 July-August 2003.

4. Thompson RE, MD "The changing face of gender issues in the 21st century workplace." The Physician Executive 31(1):64-5, January February 2005.

5. Thompson RE, MD On Beyond Compliance: Thinking Inside A Brand New Box. ACPE. Tampa. 2001.

6. Hall RT. An Introduction to Healthcare Organizational Ethics Oxford University Press, Oxford and New York. 2000.

7. Beauchamp TL and Childress JF. Principles of Biomedical Ethics, 4th Edition. Oxford University Press. New York. 1994.

8. Ross, WD. The Right and the Good. Hackett, Indianapolis, 1930.

9. Aristotle (384-322 BC). The Nichomachean Ethics. Oxford World Classics. Oxford University Press. Oxford and New York.

By Richard E. Thompson, MD