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A reflection on the practice of family medicine begins with an understanding of the ethics that guide that practice. Ethics are defined as moral principles that govern behavior. Ethical standards are informed by morality, logic, and truth. As with philosophy, a study of ethics is best understood on three levels.
The highest level is the theoretical one. This involves a rigorous logical analysis based on a core foundation of morality. This consideration is often far removed from the issues at hand. But if an idea breaks down or proves to be incoherent on this fundamental level, there is no further need of discussion.
Level two is the existential one. Here the focus is feelings, and the medium is the arts. Novels, poetry, painting, music, movies, and even social media address the issue in a manner not compelled to be consistent or correct. Even bad behavior can be painted in sympathetic terms.
The third level is a prescriptive one. The application. It is where what is considered in level 1 or 2 is converted to reality. This deals with how we should live or practice. Unfortunately, this level is where we usually start, and division occurs based on superficial differences. We need to return to level one to understand where we agree.
All three levels are important. Logic is required to understand if an idea is tenable, feelings are considered as to whether it is livable, and prescriptive discussion should begin with whether we have the right to impose moral judgments. That is, is it transferable?
The concept of transferable applies not only to the provider patient relationship, but that of the state, faith-based hospital systems and professional societies’ effort to enforce their ethical ideals on physicians. This is where an external standard upon which there is agreement is essential. I fear we are losing that. And with that loss, there is no bridge on which disagreements can meet to find resolution.
All ethics, including medical ethics, come from somewhere. If there is no referent, it is simply opinion reflecting personal preference. And that has no power to guide a profession or a society. Through the years in this country, the church has heavily influenced societal ethics. Views on marriage and family, duty of caring for the poor, abortion, physician assisted suicide – all with religious connotations.
The civil rights movement in the 60’s came largely from within church and was led by religious figures. And although the church has failed as an institution at times – when the state or political parties have determined morality – it has almost always not gone well.
We are now living in times when we moralize about politics, and we politicize morality. We moralize about politics when we describe our preference as “the right thing to do”, demonize those who disagree, or proscribe an idea as “it’s not who we are.”
We politicize morality whether the topic is abortion, expressions of sexuality, income equality, race, or gender issues. Everything is left or right. We forget there is an up and down.
I start there. Because I find it increasingly true that hospital systems, professional societies and governmental agencies wish to impose their ethical standards on our professional behavior. And the external referent is a level two existential one reflecting societal caprice. Providers should be careful in assigning this power to others.
I have also found that ethical prescriptions are often developed by policy makers who live at a safe distance from those tasked with carrying out these ideals within their personal practice. Borrowing trust that a patient places in their relationship with their physician, to mandate care. Ethics can be misused to manipulate or control behavior and speech.
Four main ethical principals often applied to medical practice are these:
1. Beneficence is an obligation to act for the benefit of the patient. As opposed to nonmaleficence, the expectation here is one of positive requirements. Not just avoiding harm, but to benefit patients and promote welfare.
2. Nonmaleficence is an obligation not to harm the patient.
3. Autonomy is founded on the principle that all persons have intrinsic and unconditional worth and should be allowed to exercise self-determination. This does not apply to persons who lack capacity including infants and children or those adults who are found incompetent.
Inherent within autonomy is the obligation of informed consent, as the patient cannot exercise self-determination without that. It requires the physician to be truthful with the patient.
4. Justice is interpreted to consider fair, equitable and appropriate distribution of health care resources. This is currently a prevailing topic within professional societies as well as the Federal and State government level. While justice is a proper goal, it provides a wide window for interpretation with opportunity of political manipulation. It’s easy to be philosophical about other people’s disease, life choices and death. Medicine is best when it is applied personally.
There it is in its driest expression. We haven’t solved anything yet. We just painted the boundaries and the yard markers on the field. The game is yet to start. Watch for the ethical context as the reality of primary care is unraveled in subsequent blogs. Watch these principals, so clear in isolation, compete for dominance as physicians grapple to apply abstract to reality.
As a practice and as individuals, we need to be clear in our own mind what is ethical in our practice. When truth is redefined as social construct and debate is suppressed, what is legal is not always right. And there have been times when what is right is punished.
Tim Powell MD