Rethinking Medical Ethics

In 2001, an article in 'Commentary' magazine asked, "Who Needs Medical Ethics?" Surely, argued authors Christine Rosen and Sally Satel, the Hippocratic Oath (Do No Harm) offered sufficient guidance to physicians and other health care providers. Weren't philosophers and bio-ethicists merely trying to develop a specialty in order to stay employed?Certainly, ethical dilemmas within medicine have presented themselves frequently. Among the most notable is the US government's 40-year study wherein hundreds of poor, black syphilis-infected sharecroppers in Alabama were left untreated to see what would happen to them. More recently, when doctors in Florida kept Terry Schiavo, 41, alive on a respirator longer than some members of her family wanted, it raised ethical questions that were followed avidly by the general public. But, wrote Rosen and Satel, "It is not at all clear what sort of specialised abilities or knowledge these trained 'experts' bring to the hospital bedside." Now, new knowledge and newly-proposed interventions arising from an increase in sexually transmitted diseases (STDs) - including HIV/AIDS -
are fostering an unprecedented environment in which to contemplate medical ethics.

One proposed action in the US is mandatory vaccination for pre-pubescent girls and young women, not yet sexually active, against the Human-Papilloma Virus (HPV) that is known to be associated with cervical cancer. Another is the wider, if not mandatory, male circumcision, a practice associated with dramatically lower rates of HIV/AIDS in African studies. Opt-out testing for HIV/AIDS - automatic testing unless
patients state explicitly they don't want it - is yet another intervention being debated.

In the past, human rights advocates and staunch defenders of individual autonomy have argued vociferously against such practices. Ethicists have argued specifically against the circumcision of male infants, claiming it constitutes a human rights violation as well as sexual assault (see 'The Bioethics of the Circumcision of Male Children', www.cirp.org/library/ethics).

Those who take a rights-based approach towards opt-out testing caution against the current push by national and international agencies to have as many people tested for HIV as possible. A statement compiled by a consortium of women's health organizations and issued during the International Conference on HIV/AIDS in 2006 states that knowing one's HIV status can have benefits, but goes on to say that "what concerns those who question the speed with which testing initiatives are being expanded is whether this public health measure will be based on respect for individual human rights." The authors cite concerns about the shortage of health care workers, lack of informed consent, and breeches of
confidentiality. Examined from a gender perspective, "testing services often do not address the stigma, discrimination and related violence, and loss of livelihood that many women face if their status becomes known. This makes seeking treatment and care a devastating prospect for many."

Ethicist Margaret McLean, Assistant Director of the Markkula Center for Applied Ethics at Santa Clara University in California, recognises that the field of medical ethics has grown increasingly "messy". The overall role and responsibility of ethicists, she says, is to look at what's at stake and for whom, to explore what values inform policy or action, and to think of what principles may apply. "We have a large plate when it comes to what questions to raise," she says. "Our job is to have a conversation that facilitates responsible decisions and actions."

Dr Larry McCullough, professor of medicine and medical ethics at Baylor College of Medicine in Houston, Texas, and a specialist in the history of medical ethics, takes a somewhat more pragmatic view. "Human rights are not a trump card," he says. "The question is what do we owe each other? We must frame the discussion around obligation, conviction, and constrained rights and then learn to live peacefully with our differences. Ultimately, it is a discourse of moral conviction. But we must keep in mind our duty to others."

McLean agrees that the common good must be well considered. Community needs, she says, can outweigh individual rights. "Human rights protect individuals, but how does that translate to collective cultures? It's a helpful lesson for those of us stuck on autonomy to realise that relationships and community also matter ethically," she says.

Levels of responsibility also change with new knowledge - a particularly sticky point when it comes to intervening within the context of industrialised countries making decisions that will affect people in the so-called Third World. McCullough poses this relevant question: "What are the obligations of immensely wealthy societies?" He points out that the US has the moral and financial resources to address massive public health threats like HIV/AIDS but the political will is lacking.

But the issue becomes even more difficult when one moves beyond such interventions as providing affordable antiretroviral therapy (ART). What happens, for example, if opt-out testing for HIV/AIDS is instituted but there is no counselling or medical service to provide follow-up care? What is our moral responsibility to girls in developing countries who can't access the HPV vaccine but who will never be tested for cervical cancer? "Do no harm is a multicultural concept," says Larry McCullough, "but how do we interpret that in terms of public policy? We must translate trans-cultural moral principles into practice."

That's a pretty tall order. Perhaps in this increasingly complex world, it's time to take another look at who needs medical ethics.