Hippocratic Oaths

Hippocratic oath insofar as a Christian may swear to it (10th Century)

Percival’s Code (1803) – Manchester England

• Stressed duty of the physician to benefit the patient and placed
no emphasis on the rights of patients (ie. Informed consent or
disclosure)

Florence Nightingale Pledge (1893) – for nurses

American Medical Association (1847)

• Began because of allopathic doctor’s need to legitimize
themselves
• Derived a code ethics – taking Percival’s Code but added on
content regarding the physician’s duties to benefit the society

British Medical Association (early 20th century) – came from AMA

World Medical Association Declaration of Geneva (1948)

• Prevents a physician from doing something against their will
• Similar to Hippocratic Oath but focuses on the rights of the
patient to not to that of the public.

Solemn Oath of a Physician of Russia (1992)

• After collapse of soviet union/post Marxist view

St. Georges University – to work for the good of my patients, according

to my ability and judgment” (rather for patient’s health)
State University of New York Syracuse

Non-Hippocratic Codes – follows liberal traditions (secular)

• Often from groups outside of health professions
• Concern with social as well as patient welfare
• Concern with duties and rights as well as benefits and harms

American Medical Association (1980, 2001)

• In 1980 there was a rewriting that talked about the “right” of the
patient this was after the 1960s-70s when rights movement
began

The Chilean Medical Association (1983)

The American Nurses Association (1985)
The Federal Council of Medicine Brazil (1988)
The New Zealand medical Association (1989)
Nuremberg Code (1946)
• As a response to Nazi physicians who used humans to further
science.
• Recognition that research is needed for the benefit of humankind
but also recognized the need to protect the individual patient
• Thus required that patients give informed consent so subjects
could look out for their own interest
• Is also different because it was a public documentation not
written by physician’s themselves

The Oath of the Soviet Physician (1971)

• Follows communist morality where sometimes the patient is
sacrificed for the good of the country

American Hospital Association Patients Bill of Rights (1973)

• Informed consent with respect to treatment is need as well as for
research
• Right to information

Council of Europe Convention on Human Rights and Biomedicine

(1997)

The U.S. Consumers’ Bill of Rights (1997)

Universal Declaration on Bioethics and Human Rights (2005)

• 10 government representatives that came together that claim to
be universal

Sources outside of Professional Medicine

• Judaism (3rd – 7th century) – Oath of Asaph, Talmudic Judaism
• Catholicism (1995) – the Catholic moral theology
• Protestantism – has positions on many medical issues that come
from moral sources fundamentally different from those of
organized medicine
• Hinduism (1st century)– Vedic texts has code of ethics called
Caraka Samhita (“Oath of Initiation”) that requires physician not
to injure or abandon the patient and not cause his death
• Buddhism – eight fold path that incorporates 5 precepts – which
include prohibitions on killing, lying and drinking intoxicants
• Ancient Chinese thought – The important prescriptions worth a
Thousand Pieces of Gold – stems from Confucianism as well as
Buddhist and Taoist thinking
o Ten Maxims for Physicians and Ten Maxims for Patients
(17th century CE)
 • Islam – Muslim oaths or codes for physicians – prepared in Kuwait
(1981)
o Strong prohibition on killing, including mercy killing and
abortion
 Affirmation of Allah’s will

Basis of Moral Standing

Moral standing – term used to describe the moral status of various
beings
• The inability to prove what characteristic establishes full moral
standing is why we continue to have controversy over the
definition of death

Defining Death
• We need to define death to see when our moral duties towards
an individual is no longer the same
• It is say that they individual have undergone a major change in
their moral status
• Cardiac definition of death – Individual dies when there is
irreversible cessation of circulatory and respiratory function.
o But there are difficulties
1. Irreversible stoppage – what about temporary cardiac
arrest without death, or open hear surgery with
heart-lung machine
2. Oriented – sometimes there are artificial hearts, thus
it’s too focused on the heart (patient Barney Clarke),
additionally what about transplant patients who are
waiting? (organs will die when heart dies)
3. Clinical death – is a meaningless and confusing term
• The Whole Brain View – an individual dies when there is
irreversible cessation of all functions of the entire brain
(including the brain stem)
o Brain is responsible for integration of all bodily functions
and when the brain irreversible stops to function, one is
dead
o Is the law in most places except
 Japan – due to traditional/cultural and religious
beliefs, but it does permit people to write out
documents that says permits the definition of brain
death in the case of harvesting organs
 New Jersey – allows individuals to but into the brain
death definition or cardiac oriented view, based on
religious beliefs
  New York – recommends that physicians can
withhold announcement of death for family’s beliefs
but is based on the determination of the physician
• Higher-Brain definition of Death – death is due to the lost of
higher brain function (this eliminates basic reflexes.. )
o Consciousness is usually considered critical in this
perspective
o This is not currently the law in any jurisdiction
o Definition of what is critical function is cumbersome – ie.
Cerebrum vs consciousness?

Abortion
• To look at the start of moral standing in exact opposition of the
end of moral standing
• The Higher-Brain View: says that fetus don’t have moral standing
until the 24th week when higher brain function begins
• Whole Brain definition – when capacity for neurological bodily
integration develops – approximately the 8-12th week
• Cardiac definition – when cardiac function appears or when it is
crucial but when the heart develops and when it functions is at
different times
• Note: the genetic view – a fetus has the potential for all the
above (unlike someone who is dead who has irreversible
damage). Thus they should be given a moral standing based on
the genetic potential.
o Sub-issues – the idea regarding Anacephaly babies – is
abortion okay for them?.. depends on which view you buy
into for moral status (whole brain/cardiac/higher brain)

Non-human beings
Two views
• Animals have a right to life
• Utilitarian view - animals should not be subject to pain
• Speciesism – discrimination against those of a different species

Problems in Benefitting and Avoiding Harm to the Patient

There are four areas of concern regarding the Hippocratic commitment
• The subjective nature of the Hippocratic commitment
• The trade-offs that must be made between medical and other
elements of personal welfare
• The different kinds of medical benefits that a physician might
pursue
• The controversial nature of medical paternalism
 Consequentialists Duty-based principles
Principles
Individual Subjective The Ethic of Respect
1. Beneficence for Persons
2. Nonmaleficence 1. Fidelity
2. Autonomy
- Hippocratic Utility- 3. Veracity
Objective (based on 4. Avoidance of
peer review, killing
utilization…)
1. Beneficence
2. Nonmaleficence
Society/community Subjective
1. Beneficence
2. Nonmaleficence

- Social Utility -
Justice
Object
1. Beneficen
ce
2. Nonmalefi
cence

Subjective vs. Objective Estimates of Benefit and Harm

• Subjective judgments – is based on the perspective of the one
making the assessment
• Objective judgments – are judgments that would be true
regardless of the person making it
• Utility refers to the assessments of benefit and harm
o The argument is that the action is morally right insofar that
it increases net utility
o But you can look at beneficence vs nonmaleficience –
actions are right as long as you maximize the good and do
not harm

• There are two schools of thoughts – each school of thought can

be applied to the individual or the society/community
o Consequentialists – focus on producing benefits and
avoiding harms, doing good and avoiding evil (Hippocratic
ethics)
 o Duty based – Deontologists – hold that some actions are
morally required as one’s duty regardless of the
consequences

• Value judgments must be made on whether a treatment is good

for the individual and the physician can’t make value judgments (it
cannot be made objectively)
• Medical judgments can’t determine what is beneficial in terms of
value judgments

2. The trade-offs that must be made between medical and other

elements of personal welfare
• Well-being includes things that are beyond the medical aspect of
life – ie. Social, psychological, economic …
o These aspects are beyond the scope of a physician
• An individual tries to balance medical well being against all the
other spheres in their life that they deem important

3. Conflicting Goals within the medical Sphere

• Prevent death, cure disease, relieve suffering and promote the
well-being of the patient can come inconflict with each other (ie.
Treating pain vs. curing disease … exacerbate pain so patient
lives longer life)

There is no definitive way that benefits and harms can be combined

numerically and evaluated
• Utilitarianism – method is to calculate the harm vs benefit for
every scenario and see which treatment is the best (Arithmetic
Approach)
• Ratio approach to benefits and harms – making calculations
regarding the ratio of benefits vs. harms (GEOMETRIC)
• Primum non nocere perspective – says to do not harm … thus the
treatment with the least amount of harm is chosen
o Do no harm vs. don’t intend harm – sometimes physicians
recommend treatments that may bring harm, but it may
still me morally tolerable provided that the harms were not
intended
o Double Doctrine effect
• Note: this is also a problem because physicians and patients
have different risk aversions… so the calculated outcomes still
depends on a “value judgment”

4. The problem of Medical Paternalism

• Paternalism – action taken to benefit another person done for the
welfare of hat person, but against his or her will
 • Hippocratic oath tells the clinician to do what appears to benefit
the patient, even if patient doesn’t agree … using their own
judgment of the utilitarian view for the benefit of the patient
• This may include harm that a patient would do to themselves

The Duty Based Principles

Deontological – based on the rights and duties of individuals
• If one person had a right to choose, then the other individual has
the duty to respect this right
• There are four principles that are included under the idea of
respect for persons
a. Fidelity – the duty to keep one’s promise, even if
consequences are not the best
• The idea of loyalty between the patient and the
physician
• Relates to the Ethics of Confidentiality
o Hippocratic approach to confidentiality – says that
information should not be exposed unless the
exposure is for the benefit of the patients and it
protects the patient from harm (determined by
that physician)
 World Medical Association Declaration of
Geneva – says that there are no exceptions
to confidentiality
o Non-Hippocratic approach – one should not
divulge information because of respects for
person’s confidentiality (with exceptions)
 BMA says that confidentiality should be kept
with the exception of when laws requires it
or when the physician has an overriding
duty to society
 AMA – says it’s okay to break the
confidentiality if a patient threatens to inflict
serious bodily harm to another person and
there is a reasonable probability that the
patient may carry out the threat
b. Autonomy – gives rise to the notion of informed consent
• Comes from traditions of Kant (liberal philosophy)
• Plays itself out in the individuals “right”
• And individual’s right and a physician’s duty are
correlative … simply put… it’s the same thing expressed
from different perspectives
• But an individuals rights sometimes can conflict with
another’s right
 • Rights’ can be expressed in a negative and positive
manner
o Negative rights – related to autonomy – a liberty
right – the right to live their life as they want
o Positive rights – are entitlement rights - based on
some principle that imposes an affirmative duty to
act
• Informed consent – the idea that meaningful information
must be disclosed even if the clinician does not believe
that it will be beneficial (THIS IS THE STANDARD)
o This goes against the view of therapeutic privilege
– which allows physicians to hold certain
information back from patient if they believe
disclosing the information will do more harm than
good.
o There are three standards to which informed
consent falls under
 Professional standard – traditional standard
that requires a physician to disclose what
colleagues would have disclosed in similar
circumstances (continues under Hippocratic
Oath, and is not adequate for informed
consent if other physicians decide not to
disclose anything)
 Reasonable Person Standard – physicians
must disclose what a reasonable patient
would want to be told or find significant (but
there is discrepancy between what
physician’s want to divulge and what a
patient would like to know)
 Subjective Standard – give patient the
information that he or she would personally
find meaningful (standard should more
subjective). The information should fit in
with the life plan of the patient. However
this may be impossible for physician to
judge and know.
c. Veracity – duty to tell the truth
• According to Kant, truth telling is a must regardless of
all expendiency (regardless of costs)
• Need to tell information regarding medical
contraindications
• AMA council – says that some information can produce
effects that the clinician should consider so bad that
 information should not be disclosed, but usually
recommends truth telling
d. Avoidance of Killing – refers to the sacredness of life or the
idea that not only should one not kill, but that one should not
take one’s own life
• Four distinctions need to be made regarding the ethics
of caring for the critically ill
1. Active killing and allowing to die
o Some believe that there is a difference (see
chart for arguments)
 Roman Catholicism
 President’s commission for the study
of ethical problems in medicine and
biomedical and behavioural research
 AMA
o Some believe that there is no difference
they believe that life is sacred and a gift and
that there’s no distinction.
 Judaism
 Right to life groups
 Groups supporting active euthanasia

Argument Counter Argument

That it feels different
Active Killing is illegal while
forgoing treatment is legal
Active killing would change the
role of the physician
Their counter arguments is that
the “feeling” that the two actions
are different is because we are
taught that it is different and it
doesn’t mean that it is actually
different
Even though it’s legal, it does not
establish that there is a moral
difference
Physician’s need not be the ones
doing the killing.

Consequentialist arguments – the idea that if a patient is terminally ill,

then there’s not difference between letting them die and them dying
later anyhow. But other’s argue that legalizing assisted suicides
resulted in an increase number of requests that doesn’t fulfill
requirements. Thus making it bad for society.

Implications for Incompetent patients and non-terminally ill patients – if

omission and commission are different and there is a requirement that
killing is only possible for patients who makes voluntary requests and
are terminally ill, then incompetent patients are deemed unable to
make the decision, and this withdrawal of life support would never be a
choice for them.

Argument from the Principle of Avoiding Killings – that life is sacred

and should be preserved

2. Withdrawing and withholding treatment

 Withdrawing is an omission – based on an
individual’s right to autonomy
 Withholding is a commission – because it is
“active” and is not based on the person’s
personal decision
3. Direct and indirect killing
 Doctrine of double effect – is the idea that
an action can lead to intended and desirable
or unintended and undesirable effects.
Doctrine holds that unintended and
undesirable effects are morally tolerable if
the action itself is not immoral, the
undesirable consequence is not a means to
the desirable one and the desirable effect
produces a great enough amount of good to
be proportional to the undesirable effect.
 It looks at the underlying motives of the
individual
4. Ordinary and extraordinary means
 Definitions based on technology – is not a
good defintion because it’s based on the
individual’s perception of what is
extraordinary and ordinary
 Based on whether is common or not – is also
not a valid definition because it also
depends on the individual
 Based on the appropriateness of
inappropriateness

 Uselessness – treatments have been

considered morally expendable if it does not
serve a useful purpose
 Grave burden – treatment serves a useful
purpose can be considered expendable if it
involves a grave burden which includes a
burden on others as well as burden to the
patient
  Proportionality – when talking about
uselessness and grave burden, you are
looking at the question of benefit/harm
ratios. But the values that underlie the
judgments of benefit and burden are
subjective and must be the patient’s values

Death and Dying – the Incompetent Patient

• There are 3 kinds of incompetent patients
1. Formerly competent patients
o Find out if patient had and advanced directives –
which are written expressions of the patient’s wishes
 Originally called the living will – allowed people to
decline measures of heroic means
 Euthanasia’s Council’s Living Will ~ Christian
Affirmation of Life – allows individuals to reject
measures of extraordinary means if there is no
reason to believe that the individual would not
recover
 President’s commission for the study of ethical
problems in medicine and biomedical and
behavioural research – allows people to decide to
forego life-sustaining measures.
 Problems – whether wishes necessarily should
remain valid when one lapses into incompentency
o Legislation – has prepared advanced
directives that clarifies individual’s options
 Attempts to legalize active mercy
killing and assisted suicide – is only on
Oregon
 Legalizing Active Killing for Mercy – in
Netherland and Australia (northern
territory)
 Natural Death Act Legislation – makes
clear that an advance directive written
while individual is competent is valid
and must be obeyed provided certain
conditions are met
o Issues with Advance Directives
 The exact treatments to be refused –
because the words to describe it is too
vague and subjective
 What treatments are desired
 When should directive take affect
  Is a durable power of attorney to be
appointed
o Substantive directives – records the patient’s
substantive wishes about medical treatments
o Proxy directive specifies the person to serve as a
surrogate decision maker in the event the patient is
unable to speak for himself or herself
o Principle of autonomy extended – is the idea that if
advance directives were written by the competent
person, it would extend over to when the person
became incompetent- but there are arguments that if
the “new” incompetent individual no likes their new life,
whether the old directives should apply
o Many times, state laws says that individuals can refuse
treatment in the case that they are terminally ill. But
the term “terminally ill” can only be applied under a
small subset … later on it was determined that a person
out to be able to decline treatment even if she is not
dying rapidly
o Living will -
2. Never-competent without family
o Must apply the principle of maximizing the patient’s net
welfare (rather than autonomy) – aka Hippocratic utility
o The Legal Standard – aka best interest standard – but
the absolute best is not always available
o Surrogate – physicians should not be surrogates
because they have biases that may not me in the
patients best interest and because physicians are
supposed to act as checks for irresponsible surrogates
and that is lost. Alternative is to assign guardians.

3. Never-competent with family

o The role of the surrogate usually goes to the next of kin
to the individual. They’re decisions are followed up to
the point that their decisions are not foolish.
o They surrogate may be held to make a decision
following the principle of limited familial autonomy.
(decisions must be made within reason)
o If family acts unreasonably, physicians could go to court
to become appointed as the temporary surrogate (ie.
For children) aka PARENS PATIAE

Social Ethics of Medicine

Social Utility – looks at beneficence and nonmaleficence applied at the
social level
Problems of social utility
• Quantification Problems – some types of events are hard to quantify
or weigh
o People calculate the cost per unit of expected benefit; the
number of years of survival from an intervention and the
quality of life that survival brings
• Problems of inequality – calculations do not address issues
regarding distribution.
o According to the principle of social utility, the morally correct
course is the one that will maximize aggregate net social
benefits per unit of resources.
o Striving to maximize aggregate net social benefits may hide
the fact that the benefits are very unevenly distributed. The
most efficient health care is not the most fair/just.

Justice/Duty based principles at the social level

• Is based on the idea that people have opportunities for equality of
well-being –meaning to distribute health services on the basis of
need.
• One must evaluate an individual’s need to determine whether they
deserve a service.
o ie. Comparing those who have a disease due to voluntary
behaviour vs. involuntary behaviours
o determining needs is then based on moment in time (triage
version) or over lifetime
• idea that the spreading of resources according to need is a duty of
ethics even if it doesn’t not maximize the total good done. This
means certain thing less “worthy” can be cut from costs in order to
reduce costs
o If it is the clinician who decides where to cut costs – then this
means that physician would be the societal gatekeeper and
would have to decide upon where to allocated money (ie.
From schooling to medicine). In this situation, there’s
physician bias. Physicians would tend to allocate money in
medicine and within their own specialty. Additionally because
physicians are consequentialists, they may tend to function
solely under the utilitarian aspect and ignore the justice
aspect when making decisions.
o The abandonment of patients for social benefit is a hazardous
one since the physician traditionally is one who advocates for
their patients. Placing them in that role would create a
conflict of interest

Organ Transplantation
• Is it ethical to transplant tissues – does it go beyond the law of
nature to transplant tissues that are human/non-human
• Procurement of organs – whether routine salvaging should be okay?
• Allocating Organs – free market type allocation?
o Question of whether it should be based on utility (best math
HLA) or based on social justice
 Issues with utility – because certain race donate more,
thus people within the race would have better match.
Additionally, younger people with higher SES have been
show to improve more, thus more utility… it causes
problems of equal access
 It is now based on social justice – people who are sicker
get the organs first

Research involving human subjects

• The difference between innovative therapy (doing everything for
the patient) and clinical research (which sometimes puts societal
interest before the inidividual’s interests – in randomized clinical
trials, we want to see if new treatment would be better than
standard treatment – this doesn’t always work with beneficence and
nonmaleficence)
• There are codes to protect that individuals from being “used” just
for social advancement
o Nuremberg Code – requires informed consent
o Belmont Code – prevents researchers from withholding
treatment if they know something out there is better
• Justice perspective recognizes a duty to ensure fairness in recruiting
subjects

Human Control of Life

• Genetic Counseling – there are issues with respect to whether it’s
going beyond the means of human beings (playing God) and
whether the counselor’s personal beliefs would sway the decisions
of the individuals
• Genetic Screening – maybe another way that advocates the
abortion arguments, which are not settled yet.
o It also makes sense to screen whole populations that are at
risk for certain diseases
o Question as to whether knowing the disease, with no
treatment, is beneficial for the patient
o Concern that insurance companies will stigmatize against
individuals who have been screen for certain diseases
• Human Genome Project – whether knowing everything there is
about the genome is a worthy pursuit
• Genetic Engineering
o Therapy vs. Enhancement – learn to ID harmful genes and
remove them or add missing ones
 Gene therapy – giving missing genes to help those with
diseases
 Gene Enhancement – when therapy goes to improve the
individuals life beyond normal (but what is defined as
normal?)
o Somatic vs. Reproductive Changes
o Reproductive Technologies
 Artificial insemination and contraception
 In Vitro – ask whether was have the right to manipulate
conception
 Surrogacy – whether a woman is liable to her
commitment of surrogacy (even if she builds emotional
bonds to the child)
 Cloning

Resolving Conflicts among principles

Different concepts of duty
• Absolute, Exceptionless Duties
• Prima Facie Duties – duties that are morally binding
• Duty proper – where there are two Prima Facie duties, we weigh one
as more bearing than the other. The one that is more weighty
becomes one’s duty proper.

Theories of Conflict Resolution

• Single principle theories – goes to deny that there is two Prima Facie
duties and that the Hippocratic Principle holds. The physician must
do what will benefit the patient. Autonomy can also play into the
situation whereby it is most important to respect the patients
autonomy (agreeing to do what they want to do) as well as the
physician’s autonomy (doing it, only if physician agrees).
• Ranking (Lexically Ordering ) Principle – to rank what is most
important and choosing the most important duty as the duty proper
• Balancing - Denies that a single principle can be found to resolve all
conflict and denies the possibility of exceptionless ranking. It
involves balance the two and allowing circumstances to dictate
which one is more important. Problem with this method is that it
relies on intuition of the decision maker. Additionally, there is
always the possibility of a counter argument which would place the
original decision in doubt.
• Combining Ranking and Balancing
Social Utility vs Justice – sometimes benefiting the whole society comes
into conflict with distributing everything justly. In these cases,
methods that are used to decide between the two are:
Rawlsian Principle – says the balancing principle (everyone is equal) is
always the rule unless inequality will give those who are worst off more
benefit.