The Methodology of Medical Ethics/Bioethics

Michio Miyasaka(Department of Nursing , School of Medicine, Niigata Univ.)

1. Introduction

Bioethics, which is an ethics for life which all people possess, has been a kind of social movement. Today, I will make a presentation mainly on the methodology of bioethics. In Japanese bioethics, an introduction of bioethics theories from foreign countries has been emphasized and little study of methodology. There has been a discussion of the difference between medical ethics and bioethics; however today I will use both words in almost the same meaning.

Context is very important in healthcare. There exist 2 main fields in health care: clinical medicine and public health. We should think of ethics for both fields. We should think of interpersonal ethics for clinical medicine and of ethics that provides a base for law for public health. Sometimes, we should think of business ethics (ex. pharmaceutical business). Please see “the Methodology of Medical Ethics" written by myself to see the total picture of medical ethics.

• History of Medical Ethics: We have had some tragedies in the history of medicine. Experiments on human bodies have been conducted under the authority of medicine. The important mission of medical ethics is to examine this history and prevent mistakes.
• Methodology:Medical ethics has been developed in English-speaking countries. Ethics in those countries is unique such as analytic philosophy, utilitarianism, and pragmatism. In those countries laws and ethics tend to be discussed differently. Ethics has become something close to religion.
• Fields:There are 4 fields: 1)death and its process(including euthanasia) 2)sex and reproductive health and rights, 3)patient's rights VS public interests(suicidal ideation, homicidal ideation, epidemic disease, etc.)4)Medical research and medical resources(it must be overlapped with science and engineering ethics. Ethics for how to allocate medical resources equally).

2. The 3 main approaches for medical ethics

I categorized medical ethics methodologies developed in Britain and US into 3: principle based approach procedure-based approach, narrative based approach.

Process for decision making in medical ethics using theory is as follows:
Step1:ethical theories such as Kantian, Muslim, and Mil's utilitarianuim.
Step2:to extract the common principles(ex. no-harm principle)
Step3:establishing guidelines and making decision

2-1. principle based approach

We make decisions by inducing from ethical principles.

(1) What is a principle?

• Principle: being in an abstract context

(2) Contents of Principles

• 4 principles in the USA :from the Belmont's reports(1978)
  1) respect for autonomy
  2) non-malfeasance
  3) beneficence
  4) justice
• 4 principles in Europe(the Barcelona declaration to Commission of European Communities in 1998)
  1) autonomy
  2) dignity
  3) integrity
  4) vulnerability

1) autonomy
In the US, autonomy has almost same meaning as right of self-determination
In Europe, autonomy has a broader meaning than right of self-determination
Autonomy is an inclusive term of various human capacities
Essence of autonomy is "self registlation" defined by Kant

2) non-malfeasance

• You ought not to intentionally create a needless harm or injury to the patient

3) beneficience

• You ought to be of a benefit to the patient (or others)

4) justice

• Justice is defined as the idea that you ought to beneficent to patients fairly. In a healthcare system, resources (human resources, money, goods) are limited. We should allocate the resources fairly.
• Justice(Fairness) is about the rules for decision of allocation.
  For example, you will judge winning or losing in sports according to rules. The rule should have been accepted by the players. We need to have rules for allocation that are acceptable for anyone even though the allocation outcome itself is not equal.

5) dignity

• Dignity is the property by virtue of which beings possess a moral status.
• It is very important to keep watching if a patient's dignity is protected or not.
  (Ex. It is important for the patient's privacy to be protected in his or her checkup)

6) integrity

• Integrity is the untouchable core, the basic condition of dignified life, both physical and mental, that must not be subject to external intervention.
• Dignified life has some coherence, which should be respected and protected. A human being has a coherence of life which is remembered from experiences and therefore can be told in a narrative.

7) vulnerability Vulnerability expresses two basic ideas.

1. It is the finitude and fragility of life which, in those capable of autonomy, grounds the possibility and necessity for all morality.
2. It is the object of a moral principle requiring care for the vulnerable. The vulnerable are those whose autonomy or dignity or integrity are those whose autonomy or dignity or integrity are capable of being threatened.

2-2. Procedure-based approach

Procedure-based approach is clinical ethics in which we focus on decision making or practice rather than theory. Ethical decisions in health care should not be only a personal decision, but also a group decision by health care professionals, and also group decision by the patient, the professions, and the family members.

Recently, a lot of guidelines have been established. That is because the pressure for health care practitioners to make a correct decision is becoming stronger. A lot of laws, codes of ethics, guidelines, clinical pass are being established.

2-3. Narrative based approach

In narrative based approach, we think of principles in the context of the patient's life history.

Principle based approach: no harm principle
Procedure-based approach: Does this medicine cause side- effects?
Narrative based approarch: What is the harm for this life?(Context of life) ex)He should give up his hobby, singing songs.

Relativization of the multilayered viewpoints

1) Story from the Doctor's viewpoint
2) Story from the Nurse's viewpoint
3) Story from the patient's viewpoint
4) Story from the Family's viewpoint

There are 2 ways to resolve the discordance: assimilation and dissolution. Assimilation: patients are persuaded by the professions to follow the profession's story. Dissolution: they create a new story by exchanging their original stories

3. Ethics in medical/biological research

Objectives of study:
Therapeutic Study: the objective of the study is beneficence to the patient
Non-therapeutic Study: the objective is scientific investigation

Tragic history such as the experiments on human bodies
->The right of subject of medical experiments

We have had different ethical standards for therapeutic study and non-therapeutic study. We have had a stricter standard for non-therapeutic study than a therapeutic one. (Ex. cloning: We have a stricter standard for reproductive human cloning than for therapeutic human cloning.)

Subject of experiments: human being/others

Q&A:

1. Asian Principle
Q: Have you ever discussed an Asian Principle in medical ethics?
A: Dr. Hyakudai Sakamoto established the Asian Society of Bioethics and has studied it for 10 years. He has emphasized Asian Values; however some have criticized it. He said that American bioethics emphasis autonomy or right of self determination too much even though they tend to make a decision taking into account others' opinions in Asia. Some have questioned his view. They said they have same kinds of idea, communitarianism, also in America. Is it OK to think that communitarianism is the essence of Asian Values? And Sakamoto and his group could not show how to establish Asian way of decision making without taking account of family value. And also, some criticized that his idea was short of enough reflection on tragic history including experiments on human bodies.

2. Ethics Education
Q: I would like to know about the ethics education in Medical Schools in Japan. Is it based on a principle-based approach, procedure based one, or narrative-based one?
A: It is important to teach medical ethics with using all of 3 approaches. Principle approach education is important to educate one's think the problem logically. And narrative based approach is popular in medical ethics education. Education using scenarios and role plays is effective.

3. Britain and US style/European Style
Q: I also experienced the difference between Britain-USA and European approaches (ex. WTO). Do you think if it is possible to mediate between them?
A: Legislations on bioethics are being established according to the principles. Different principles induce different legislation. The continental principle induce a less strict legislations; the European one induce stricter ones (ex. human genome). If each country has different legislation, patients and researchers may move to the less strict countries. We don't have a good measure for this problem. It is very complex problem of how to answer global problems. What should we think of “nation" in health care problems? People of a nation are the people who pay tax to a government and receive their services; on the other hand, people have rights to move to another nation. How should we protect the rights of the people of the developing countries? I think we should find some way to make agreements with each other.

4. Oath of Hippocrates
Q: I would like to ask about Oath of Hippocrates. Do the most of health care professionals know Oath of Hippocrates by heart?
A: Oath of Hippocrates is called the origin of medical ethics. I think few students know Oath of Hippocrates by heart and a few students know the contents of the Oath. In the present education of medical ethics, we teach it as a part of history. It has similarities and differences to the modern ethics. The big difference is Oath of Hippocrates did not include the concept of autonomy. Some say that Oath of Hippocrates is a symbol of paternalism.
Q: Then, do they remember the modern code of ethics?
A: To remember the code of ethics is a kind of procedural approach. I think it is more important to learn how to think logically and apply the principles. So I don't want to promote education to remember the code.
Q: Don't you teach that health care practice is a benevolent art rather than a business ?
A: I think health care professionals or medical students should be more interested in management including cost in Japan. We have to have a big challenge on health care cost in the aging society.
Q: The question I asked was if health care professionals discuss the essence of health care practice as a business or benevolent art.

5. Bioethics and Buddhism
Q: I am a researcher of environmental ethics. I feel western ethics has Christianity as a background and that Buddhism has different way of thinking from it. So I think there may be another way of thinking for Asian bioethics from the western ones. What do you think about it?
A: When they established the European 4 principles, they confirmed that they would allow the religious diversity in the European principles. This is only my personal opinion, but they don't have a rule on integrity in Eastern religion such as Buddhism and Confucianism. Japanese people hate the dead body is injured; however they don't have a strong sense of integrity according to Buddhism and Confucianism.