Medical Ethics

Medical ethics are concerned with moral questions raised by the practice of medicine and, more generally, by health care.

Medical ethics are concerned with moral questions raised by the practice of medicine and, more generally, by health care. Because of the increasing importance of health care to an aging population within a society wealthy enough to afford it, and because of the increased complexity of health care, and the reduced reliance upon tradition and authority in moral matters, debate over issues in medical ethics has grown more intense. Certain issues present particularly difficult ethical dilemmas.

Physician-Patient Relationship

How much information is a patient entitled to receive before accepting or refusing treatment? Is a physician or other health provider ever permitted to deceive or withhold information from a patient? To what extent, if any, may a physician's personal moral or social beliefs influence his or her relationship with and advice to a patient? The Hippocratic Oath, which is still administered in many (but not all) medical schools, omits any reference to a moral obligation on the part of physicians to be honest with their patients. Traditional medical ethics were paternalistic; information was given or withheld as doctors thought best. For more than a century, however, courts in the US, Britain and Canada have ruled that a mentally competent adult patient is entitled to all information necessary to give informed consent to treatment. Nevertheless, ascertaining the true wishes of a patient may not always be easy, eg, the patient may be seriously ill, drugged, in pain, depressed or may be less than fully rational and competent. As a result, physicians are not necessarily released from the obligation of using their own judgment to determine, at least in the short term, what is best for the patient.

Reproductive Technology and Medical Interventions

Besides the issue of abortion, questions have been raised about artificial methods of inducing pregnancy, eg, by donor artificial insemination and in vitro fertilization; about gestation, eg, surrogate motherhood; and about various contraceptive techniques and surgical sterilization procedures. The ever-increasing pace of discovery in the field of genetics, in part associated with the effort to map the human genome (see Human Genome Project), has fostered new questions about genetic testing for disease and the propensity to develop disease (see Genetic Diseases). With the onset of research in gene therapy, which in some cases (such as in germ-line gene therapy) will affect the progeny of the patient being treated, further moral quandaries are bound to arise.

Death and Dying

When breathing and heartbeat are temporarily sustained by machine in a patient without brain function, is that patient alive or dead? Should it be permissible, for example, to harvest organs from such an individual for the purpose of organ transplantation? Additional new and looming issues in transplantation arise over the use of anencephalic newborns and of xenografts, organs harvested from animals that may have been genetically altered to make them more immunologically compatible with humans.

Is a health practitioner permitted to provide life-sustaining treatment to a patient who has forbidden medical treatment? Does the dying patient have the right to be assisted should he or she wish to commit suicide? Alternatively or in addition, should physicians be free to follow their conscience in complying with a patient's request for euthanasia? In these questions the value of the sanctity of life, that every life must be preserved at all costs, is frequently at odds with the value of the quality of life, according to which an individual has a right to a humane and dignified death. Whether and when to use technology to prolong the life of infants with severe genetic diseases is one of the most difficult decisions health-care practitioners and society must make, and it involves again the conflict between sanctity and quality. Those who advocate what is sometimes called medical vitalism support the former and argue that the potential abuse of quality-of-life judgment is enormous; their opponents argue that concern for relief of suffering and a dignified death will help promote a society more sensitive to human life (see Death and Dying).

Another continuing debate concerns the concept of medical futility. May a physician autonomously decide to withhold a certain treatment from a patient on the grounds that its provision would be futile? Can this judgment only be made on the basis of the inability or extreme unlikelihood of success, or can a treatment also be judged to be futile when the patient in question will never personally experience the benefit of the intervention, eg, when the patient is in an irreversible persistent vegetative state, devoid of cognition?

Special Patient Populations

Who should decide treatment on behalf of severely handicapped newborns (or any group who cannot speak for themselves), and on what basis should these decisions be made? In some ethnic groups, an extended family (including grandparents) is involved in the rearing of children. Are there therefore special circumstances in which the extended family should be involved in medical decisions regarding newborns?

Much ethical debate has also arisen with the advent of the HIV (human immunodeficiency virus) epidemic (see AIDS). Special concerns have been raised in the areas of confidentiality (when, if ever, can a person's HIV status be disclosed against his or her will?), the right to health care, discrimination and the conduct of research with human subjects (see below).

Canadian medical research is mandated especially to consider the ethics surrounding research with groups traditionally excluded from research. These include women, vulnerable people, and Aboriginal peoples. Medical researchers must consider the ethics of working with or refusing to work with these groups, because medical research is required to benefit all Canadians. Special considerations must be made by researchers when working with Aboriginal communities or pregnant and breast-feeding women, such as respecting cultural perspectives and the ethical needs of the fetus or child.

Economic and Social Policy

Do patients have a right to health care regardless of expense? When patients' needs exceed available health-care resources, how should those resources be distributed? Considerations of social welfare have traditionally been used to justify intervention into the physician-patient relationship, eg, physicians have been required to report on patients with gunshot wounds or communicable diseases. The question arises about to what degree health professionals should act in accordance with the best interests of their society.

Fundamental issues about the just provision of health care necessarily resurface at times of governmental fiscal constraint, when the economic arrangements for health-care provision are altered. Such debates are engendered, for example, when provinces close hospitals, suspend payment for certain medical services or allow the opening of private, for-profit clinics.

Research and Experimentation upon Human Beings

When is experimentation upon children justified? Is it ethical to proceed with an experiment that requires the subject of research not to know whether the drug he is taking is a sugar pill or pharmacologically active?

Medical research on humans has always been a difficult ethical issue. New technologies, and better understanding of the role of genes in disease and the mechanisms of disease in people have further complicated the matter. The former practice of only conducting medical research on men, for example, led to women being prescribed medications that had not been duly tested on women. It also led to incorrect assumptions being made about the differences and similarities of symptoms of cardiovascular disease among men and women.

Stem cell research is an example of an area of medicine that raises ethical concerns for some Canadians. The federal government is sensitive to the social climate in which medical research is practiced, and has permitted some types of stem cell research and not others. Any research that could involve a profit motive is not permitted, nor can human embryos be created for stem cell research purposes.

Technology has the potential to cause ethical issues in the future. The ability to manipulate genes in embryos could lead to people selecting traits that eliminate characteristics considered undesirable by some individuals, such as brown eyes.

Medical research institutes adhere to a variety of formal policies and procedures to protect the ethical integrity of the research, and work toward improving the health of all Canadians. The universities, research institutes and health-care facilities that are involved in working with humans are regulated in order to ensure that ethics in research is standardized across the country. The common institutional umbrella under which health care and research is conducted in Canada makes ethics of equal importance for all practitioners.

Individuals and Organizations Involved in Medical Ethics

Legal and governmental bodies are concerned primarily with the public regulation of health practices. An influential early initiative came from the Law Reform Commission of Canada, which established the Protection of Life Project in 1976. This project, which ended in 1992, issued reports and recommendations on topics such as the definition of death, euthanasia and the withholding of treatment, behaviour control techniques and experimentation with human subjects. Provincial law-reform commissions have also issued reports on aspects of ethics and health care, eg, children's consent to medical procedures (Alberta, 1975); artificial insemination (Saskatchewan, 1981); and new forms of human reproduction (Ontario, 1984). A lengthy, multimillion-dollar exercise in public medical ethics came with the federal government's establishment of a Royal Commission on New Reproductive Technologies, which submitted its final report in 1993. This Commission conducted polls and funded ethical and empirical research to serve as the basis for its recommendations for governmental regulation of in vitro fertilization, among many other reproductive technologies.

The recommendations of the 1993 Royal Commission included supporting some reproductive technologies and not others, and establishing a federal agency to regulate reproductive technology. In 2004 the federal government passed the Assisted Human Reproduction Act which addressed the concerns of the Royal Commission from ten years earlier. The Act banned various practices including human cloning, the sale of ova and sperm, sex selection of embryos, and any combination of human and animal DNA. Other practices were permitted such as surrogacy, assisted conception, donating reproductive material and stem cell research. The legislation also required the establishment of the Assisted Human Reproduction Agency of Canada (AHRAC), which occurred in 2006. The AHRAC regulates human reproductive technologies in Canada and enforces the provisions of the Assisted Human Reproduction Act.

The passing of the Assisted Human Reproduction Act in 2004 regulated medical ethical issues. The Act is meant to be a comprehensive compilation of ethics relating to assisted reproduction in Canada. The regulations prohibit the cloning of human embryos and using human reproductive material in non-humans, the payment of women for surrogacy services and purchasing eggs or sperm from donors, use of a person's reproductive material without their informed consent or the use of a minor's reproductive material in any situation regardless of consent.

Views of legislators on some issues of medical ethics may be expressed in provincial Acts governing the conduct and licensure of the health professions, as well as in special enactments (eg, Manitoba's Vital Statistics Act, which defines death, and the Human Tissue Gift Acts, governing transplantation, which were adopted by a number of provinces). In 1991, major legislative initiatives in connection with medical ethics and the doctor-patient relationship were passed in Ontario, with the Consent Act and the Substituted Judgment Act, and in Québec, which revised its Civil Code.

Cases brought before courts may involve the judges in intricate questions of medical ethics, such as whether physicians are obliged to advise patients against relatively useless surgery (Zamparo v Brisson, Ontario Court of Appeal, 1981); whether a physician, when informing a patient of the risks and benefits of a medical procedure, should take into account the patient's economic situation (Reibl v Hughes, Supreme Court of Canada, 1980); and whether the parent of a person with a mental handicap may authorize that person's surgical sterilization (Re Eve, Supreme Court of Canada, 1986). In 1993, the Supreme Court of Canada ruled, by a 5-to-4 margin, that the legal prohibition of physician-assisted suicide does not violate the Canadian Charter of Rights and Freedoms (Rodriguez v Attorney General of Canada, 1993). In 2009 the case of a minor who was forced to receive medical treatment against her religious views came before the Supreme Court. The court ruled, by a 5-to-4 margin, that specific age limits apply when people wish to refuse medical treatment because a child may not possess the necessary intellectual appreciation of the consequences of refusing medical treatment (A.C. v Manitoba, 2009).

Organizations of health professionals are involved in establishing codes of ethical behaviour on behalf of their membership. Some have committees charged with enforcing ethical behaviour, or with studying ethical problems that arise in the profession. A code of ethics for physicians established by the Canadian Medical Association has been revised on a number of occasions.

In 18th-century England, a long, highly detailed code was formulated, but current codes usually consist of a brief set of abstract principles that need to be supplemented by guidelines governing implementation. The codes do not, of course, preclude the occurrence of serious conflicts and ambiguities, and in fact may sometimes help inspire them. Also, while a code may represent the ethical view of the profession, physicians may not necessarily be familiar with it. As far back as 1880, an editorial in the Canada Lancet complained that most doctors were not familiar with the code, and a 1983 survey of 300 Toronto physicians found that 68% had never read the code and 84% could not say whether references were made in it to abortion or to organ transplantation.

The College of Physicians and Surgeons of Canada updated the physicians' code in 2004. The code addresses ethics on a variety of levels including participating or advising participants in medical research, promoting equitable access to medical care for all Canadians, encouraging awareness of environmental and social factors that influence patient health, respecting patient confidentiality and ensuring that medical research is undertaken in an ethical manner.

Legislation may require professional associations to establish committees to monitor ethical conduct. Independent committees on ethics have been established by the CMA (which also has an internal office of bioethics with professional staff), the Royal College of Physicians and Surgeons of Canada and specialty groups such as the Canadian Pediatric Society and the Canadian Infectious Disease Society. In 1988, the National Council on Bioethics in Human Research was established with the support of the Medical Research Council, Health Canada, and the Royal College of Physicians and Surgeons, joined in 1994 by the Natural Sciences and Engineering Research Council and the Social Sciences and Humanities Research Council. Some lay associations and church groups also issue statements representing members' views on specific issues in medical ethics, eg, the United Church of Canada issued a report on ethics and genetics in 1978.

Courses on medical ethics became widely available in the 1970s. Canadian universities and some colleges offer at least one and sometimes several undergraduate courses. Coursework in ethics is required for medical residents at all Canadian medical schools, as mandated by the Royal College of Physicians and Surgeons of Canada. All of the basic principles and processes of medical ethics are addressed, including: knowledge of ethical theories and issues, ethical dimensions of all medical decision-making, and the personal ethical choices of residents. The college also requires that knowledge of ethics and ethical behaviour be evaluated before medical accreditation is granted.

Graduate instruction is also available in some Canadian universities; no longer confined to departments of philosophy, theology or religious studies, integrated graduate degrees in bioethics with interdisciplinary training were introduced in some Canadian universities in the 1990s. Because of year-to-year variations, it is difficult to say how many hours of instruction in bioethics, on average, are included within the medical school curriculum. Growth in this area, though, is beyond dispute. For several decades prior to the 1970s, formal ethical instruction included within the medical curriculum was the exception; today, it is the rule.

Research into aspects of medical ethics is conducted by individual scholars from many disciplines, including the health professions, the humanities and the social sciences. In addition, research institutes investigating questions of medical ethics have been established in a number of Canadian cities including Montréal (Centre de Bioethique and McGill's Division of Medical Bioethics), Toronto (Centre for Bioethics), Vancouver (UBC Centre for Applied Ethics) and London, Ont (the Westminster Institute). Institutions involved in medical research have commonly established ethics committees to review the ethics of proposed research programs. These committees refer to guidelines on the ethics of research jointly established by the Canadian Institutes of Health Research (CIHR), the Social Sciences and Humanities Research Council and the Natural Sciences and Engineering Research Council. Increasingly, hospitals and other institutional providers of health care are establishing internal ethics committees to additionally consider their own practices and those of their staff.

The Institutes of the CIHR are responsible for ensuring that all health research in the country adheres to legal ethical standards. The CIHR is mandated by Parliament to adhere to the highest international ethical standards, apply ethical principles to health research, and monitor and evaluate ethical issues. Ethics is a shared responsibility that extends across all levels of the CIHR. The standing committee on ethics identifies emerging ethical issues, the ethics office develops and implements ethics in research policies, each institute advisory board considers ethics in the mandate of the institute and has a formal ethics designate, and peer review committees that help to determine project funding include a focus on ethics. There is additional support for ethical issues related to research integrity and stem cell research.