Dennis Sullivan, MD, MA (Ethics)Director, Center for Bioethics

Cedarville University

Center Website: www.cedarville.edu/bioethicsEmail: sullivan@cedarville.edu

Objectives:

To review the major principles of modern biomedical ethics

To provide a historical context for these rules To consider how these principles may need

modification in a cross-cultural context

2400 years of normative medical practice Exemplified by the Hippocratic Oath (400

B.C.) Four Rules:

Beneficence Non-Maleficence Distributive Justice Autonomy

1Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2013. 

H: “I will apply treatment for the benefit of the sick according to my ability and judgment.”

Always acting in the best interest of a patient

H: “I will keep them from harm and injustice.”

“Primum non nocere:” First, do no harm (L. version first said by Galen)

Two specific prohibitions: no assisted suicide no abortion

Treat everyone the same, regardless of… H: “Whatever houses I may visit, I will

come for the benefit of the sick, remaining free of all intentional injustice, of all mischief, and in particular of sexual relations with both male and female persons, be they free or slaves.”

Remarkable in a Greek society where women and slaves had no rights.

The fourth dictum of medical principlism

Never even implied in the Oath, but very important today

Gives rise to the idea of informed consent

Professionalism Medicine is a high calling The oath is akin to ordination

Confidentiality Keeping medical information private H: “What I may see or hear in the course of

treatment or even outside of the treatment in regard to the life of men, which on no account ought to be spread abroad, I will keep to myself, holding such things shameful to be spoken about.”

Medical ethics seminar in New Delhi, India Roopa: Pro-life (adopted an abandoned baby girl)

But had trouble when I said I would refuse to refer a patient for abortion

New Delhi conference: physicians not willing to terminate life support

“Always wrong” It is euthanasia According to these Christian physicians

In fact, withdrawal of futile treatments is quite ethical (with strict qualifications)

Western idea From Immanuel Kant and the Enlightenment Patients are willing and able to make their

own decisions Implies a strong degree of individualism

Not always true of developing cultures!

“Don’t tell my wife she has cancer” Common request by a loving African husband In fact, she is illiterate and probably cannot comprehend the

facts More sinister:

22 year old man with gangrene of left foot Needed amputation, consent by parents and him Blocked by village chief

Confidentiality Story of pastor with AIDS With tears: “I only cheated on my wife one time!” I spent over an hour, promising not to discuss his

infidelity with anyone

Women have few rights (in the Western sense)

AIDS, FGM, and poverty add to the gender disparity

Few women recognize the disparity We cannot correct these disparities at

the bedside A clinician must accept these things

and live within the system

Long-standing cultural practice

Koran: up to four wives (though may be over-interpreted by Christians)

May be more related to folk Islam than high Islam

In Africa, 4th wife is often very young (12-14) Belief that this will give an older man vigor Pregnancy: “children having children” CPD ischemic damage to anterior

vaginal wall VVF constant leaking Women then abandoned, stigmatized Repair of VVF is a ministry opportunity

How much do we practice Western medicine? Example of AAA in patient with Marfan’s

Syndrome Decided not to operate (for the greater good)

Paternalism Not our habit But given the lack of education, may be the best

policy Resource limitations

Frustrating Can be a big cause of overwork and burnout

 

Four Rules: Beneficence Non-Maleficence Distributive Justice Autonomy

Other aspects Professionalism Confidentiality

Remember: “The rules are the same, but the context is different.”

Dennis Sullivan, MD, MA (Ethics)Director, Center for Bioethics

Cedarville University

Center Website: www.cedarville.edu/bioethicsEmail: sullivan@cedarville.edu