Medical ethics is an area of applied ethics that pays special attention to the moral issues and problems that arise in the
context of medicine. Some issues are as old as the practice of medicine, such as the roles and responsibilities of health care providers, the nature of the doctor-patient relationship, and access to health care. Others have developed alongside many of the advances in medical technology.
In the United States, there has been a shift in the relationship between doctor and patient. For many years the relationship was paternalistic: the doctor determined what course of
treatment was in the patient's best interest, and the patient consented to treatment. Now many patients make the final treatment decisions. The notion of informed consent plays a crucial role. Since patients make treatment decisions, they must have adequate information about diagnosis, alternative possible courses of treatment, including a choice not to treat, and the benefit and risks of each option.
Physicians must ensure that the patient understands the treatment options.
Sometimes assessments must be made of a patient's ability to make a decisionÑfor example, in patients with geriatric dementia. When a patient is not able to make treatment choices, a proxy may be appointed to make choices in the patient's best interests. A closely related question is that of euthanasia, ordinarily the termination of extraordinary treatment of so-called hopeless cases. Voluntary euthanasia may be requested by the affected individual, but if the patient is unable to do so, involuntary euthanasia depends on the family or attending physician. The ethical values of each party differ, and a process of cooperative decision making may be required.
Access to health care is a major ethical issue. In the United States, unlike many other industrialized countries, health care is available to those who are insured, or who can pay out of pocket. Those who cannot afford these options and are not poor enough to qualify for Medicaid historically have gone without adequate medical care.
In recent years a system of health maintenance organizations and managed care has developed, giving rise to a whole new cluster of moral issues. Most HMOs tie the financial interests of their employee physicians to the financial goals of the HMO. Some HMOs vary doctors' pay with the level and amount of patient services provided, so that a doctor who orders expensive tests for patients or refers patients to more expensive specialists has his or her pay correspondingly reduced. Other HMOs tie doctors' incomes to the number of patients seen; the incentive here is to see as many patients as possible, which can preclude patients getting careful medical attention. Furthermore, under managed care, approval for medical services is often the decision of someone in the HMO office rather than the doctor treating the patient. This can remove health care decisions from both the doctor and the patient.
The application of new medical technologies is continually a source for ethical issues. In vitro fertilization has raised questions about the moral status and ownership of fertilized eggs. Advances in intervention in head trauma cases allow many people with major brain injuries to survive when in the past they would have died. Some of these patients can fully recover, but others end up in an unconscious vegetative state and can remain alive in this manner for many years. Organ transplantation and the scarcity of available organs raises issues about allocation: who gets the liverÑthe otherwise healthy 15-year-old or the 30-year-old parent and recovering alcoholic. Many hospitals have established committees to deal with such so-called triage decisions.
Genetic engineering has made gene therapy possible. Somatic cell therapy, used on humans in the United States since 1990, affects only the patient. Germ line therapy, which has not yet been used in humans, would introduce genetic modifications not to the patient, but also to the patient's possible offspring, which raises the question of the moral permissibility of modifying a genetic line.
Ethical codes for physicians include the American Medical Association (AMA) Code of Ethics and the Hippocratic oath. Both stress the importance of confidentiality and the need to treat patients with dignity and respect. Highly transmissible diseases such as AIDS can pose an ethical dilemma. Some physicians are choosing not to treat people with these kinds of diseases, on account of the risk of accidental infection. AIDS-infected physicians or health-care workers also face a dilemma: Although the risk of doctor-to-patient transmission is believed to be minimal, the question is whether, with proper precautions, physicians with AIDS should continue to treat patients.