Chapter 2

Ethics and Morality

Objectives: At the end of the topic, the student should be able to do the
following:

1. Discuss the history of medical ethics.

2. Explain the two ethical theories.
3. Compare morality, ethics, and law.
4. Define ethics, professional ethics, and medical ethics.
5. Discuss the different ethical principles.

History of Medical Ethics

The first attempt at defining medical ethics began about 4,000 years ago
when the ruler of Babylonia created the Code of Hammurabi, the first
recorded set of laws in human history. These laws included acceptable
standards for the practice of medicine and were specific to their time and
culture. For instance, if a surgeon saved a patient’s organ from a tumor, he
received 10 shackles; but if the patient were to die on the course of treatment,
the doctor’s hand would be chopped off.

Approximately 1,500 years later, the Greek physician Hippocrates (460-

370 BC) wrote the Hippocratic Oath, which defined the ethical standard for
practicing physicians. The Hippocratic Oath is an oath historically practiced
by physicians wherein a new physician requires swearing to healing gods to
uphold ethical standards. Hippocrates is considered the most outstanding
figures in the history of medicine. He is often referred to as the Father of
Medicine. The Hippocratic Oath is the earliest expression of medical ethics in
Western countries which remains important until today. The oath includes the
principles of confidentiality, beneficence, and nonmaleficence. Refer to Appendix
2 and 3 for the original and modern version of the Hippocratic Oath.
 Hippocrates (460-370BC)

His approach revolutionized medicine from the ancient past and began
turning it into an objective science. He believes that people practicing medicine
should be pure and holy. Hippocrates's teachings addressed mental illness,
depression, and anxiety. His writings had reached the Roman Empire and
throughout the world.

In 1803, Thomas Percival, an English health reformer and medical

doctor published a document describing the qualifications and duties of
medical professionals. It coined the term “medical ethics” and “jurisprudence”.
Percival’s Code of Medical Ethics emphasized the Hippocratic tradition and
professional etiquette and was written for physicians who are practicing in
medical institutions, thus adding institutional considerations to the focus on
patients’ welfare. The practice of medical ethics becomes widely accepted and
practiced around the world.

Thomas Percival (1740 – 1804)

In the 1930s, medicine was a paternalistic profession wherein patients

are devoid of the freedom to make their own decision. Doctors gave advice, and
patients were expected to follow along. Patients did not have many rights. They
could be enrolled in experiments without their knowledge. Such practices have
included denying patients the right to informed consent,
using pseudoscientific studies such as race science, and torturing people
under the guise of research.

Pseudoscience consists of statements, beliefs, or practices that are

claimed to be scientific but are contradicted with the scientific method. The
word pseudoscience is derived from the Greek root pseudo meaning “false”, and
the Latin word Scientia, meaning “knowledge”. Moreover, race science is a
pseudoscientific belief wherein research involves racial discrimination, racial
inferiority, or racial superiority.

During World War II (1939-1945), Imperial Japan and Nazi Germany

performed brutal experiments on prisoners and civilians through groups like
Unit 731 in Japan or individuals like Dr. Joseph Mengele.

Unit 731 or the Ishii Company was a secret biological and chemical
warfare research and development facility. The facility was responsible for
some of the most notorious war crimes researching by experimenting on
humans, most specifically prisoners. The prisoners were killed in gas
chambers. They also performed field testing by dropping bombs on several
cities in China to see whether they could start plague outbreaks.

In Germany, Dr. Josef Mengele (Angel of Death), a German officer, and

physician under Adolf Hitler performed deadly human experiments on
prisoners to be killed in gas chambers. He ordered the kidnapping of almost
3,000 twins. He conducted research brutal experiments on them performing
forced insemination, injections with diseases, amputation, and murder. Those
that died were dissected and studied and the surviving twins were killed by gas
chambers.

Unit 731 in Japan

 Dr. Mengele’s experiment on twins
After World War II, the world learned about the horrors of these brutal
experiments and was widely condoned. Efforts were done to promote safe and
exercise freedom in medical research. The Nuremberg Code was introduced
which also signaled the beginning of modern medical ethics. The Nuremberg
Code is a set of research ethics principles for human study. The code includes

 voluntary consent,
 the fruitful result for the good of society,
 no physical or mental suffering,
 no harmful complications, and
 the degree of risk should never exceed the humanitarian importance of the
problem to be solved.

For several decades, it became the accepted norm in medical ethics.

While the Nuremberg Code became an accepted practice, in 1972, the

untold story of the Tuskegee Syphilis appeared in the media. Tuskegee Syphilis
is an Alabama (U.S.A) study of untreated syphilis in black Americans. It ran for
more than four decades involving almost 400 impoverished and poor black
American men. The study started in 1946 by the US Public Health Service who
deceived black Americans to enroll in their study with the offer of free
healthcare. The participants were never told they had syphilis and were never
treated for it even when penicillin became a standard treatment in 1947. They
were lied to by telling them that they have “bad blood” instead of informing
them that they have a contagious disease. The study aimed to know whether
syphilis affected black Americans differently from white Americans. The main
purpose of the study was shallow and the risks are higher than its benefits.
 In the 1960s and 1970s, medical ethics transformed a dramatic shift and
was reconfigured into bioethics. The moral foundation of modern biomedical
ethics is based on four prime factors:

 autonomy,
 beneficence,
 nonmaleficence, and
 justice.

Today, the principles and values of medical ethics have achieved a great
deal of acceptance within the medical community. The field is divided into four
areas-hospital ethics, ethics at private practices, clinical research, and public
health.

Language of Ethics

Morality focuses on the “good” or “right” answer to a problem or

dilemma arising from a conflict involving fundamental human values. It is the
fundamental standard of right and wrong that individuals or society learn from
their culture and traditions. Ethics – sometimes called moral philosophy- is
the branch of philosophy concerned with how we ought to live. It refers to the
study and analysis of morality. The English word “ethics” comes from the
Greek word ethos which means “character” or “custom”. Therefore, ethics
combines the meaning of the word ethos with the wider meaning of the word
ethics. Ethics are moral principles that take a systematic approach to define
social and individual morality.

The study of ethics is the study of moral values, which values are most
important, and which standards of morality we should require one another to
adhere to.

Although morality and ethics are frequently used interchangeably, notice

that morality focuses on what should be done in a particular situation while
ethics focuses on why a particular course of action is the right one.
 Ethics are moral principles that govern a person’s behavior to choose right from
wrong. Photo by: Pixabay

Many professions promulgate ethical codes which are the specific

standards for ethical conduct. Professional codes offer a guide and a way
forward in one's effort to be moral in the practice of the profession. This is
called professional ethics.

Professional ethics refers to a code of ethics as applied to questions

concerning a particular profession. Often accepted ethical tenets of the
profession in question are kept by professional groups in ethical codes, ethical
guidelines, or ethical statements. Underlying this focus is the question, “What
kind of person should I be to fulfill my obligations as a professional?”

Medical ethics also called health ethics/health care ethics, is the study
and analysis of moral issues (issues of right and wrong) as applied to the fields
of medical treatment and research.

Ethics, Morality, and Law

There is some overlap between ethics and the law, but they are not
always in line with one another. An ethical act may not be legal. For example,
consider speeding. Speeding is illegal, but it does not mean it’s unethical. It
seems ethically acceptable to speed to get someone to the hospital for an
emergency, for instance. One may be punished according to the law, but it
does not automatically make a person’s act unethical.
 Also, an unethical act may not be illegal. Cheating on one’s girlfriend or
boyfriend may be unethical but it is not illegal unless the person is one’s
legitimate husband or wife. Cheating on one’s spouse is a criminal offense.

Moreover, an act can be unethical but still moral. Robin Hood steals to
feed the poor was considered unethical but still moral.

Are all legal things ethical and should all unethical things be illegal?

The fact that something is legal doesn’t make it ethical. For example,
lying is considered legal unless if one is under oath. Lying under oath
corresponds to perjury, which is a criminal offense. Simply lying is generally
recognized as being unethical but not illegal. Moreover, breaking a promise is
also legal unless a contract is involved. Breaking a contract corresponds to a
breach of contract, which is a civil offense. Breaking a promise, in general, is
considered unethical but not illegal.

The law may be inspired by ethical standards, but in many cases, it is

better not to make laws about unethical behaviors because people usually sort
out these kinds of things. Besides, it could simply be too expensive to enforce
some laws. For example, lying is unethical, but how full would prisons be if
they had to hold all the liars in addition to the thieves, tax evaders, murderers,
and sex offenders?

Ethical Theories

The following theories form the foundation of normative ethics conversations.

Healthcare professionals must understand how to apply these concepts to the
actual practice of the profession.

1. Utilitarianism – it is an ethical theory that considers an action as morally

right if its outcomes or consequences are good for the greatest number of
the population. It determines right from wrong by focusing on outcomes.

It focuses on the “greatest good for the greatest number”. This theory
disregards individual rights and considers the welfare of the majority to be
the most significant factor.
 For example, in 2019, during the swine foot-and-mouth disease
outbreaks, pigs were slaughtered within a 50-mile radius to stop the
spreading of the disease. The culling caused a devastating economic effect
on the part of the livestock owners. In this situation, the welfare of the
greatest number of people is more important than the economic interest of
the individual: livestock owners.

On the other hand, utilitarianism believes that the purpose of morality is

to make life better by increasing the number of good things (pleasure and
happiness) in the world and decreasing the number of bad things (such as
pain and happiness).

In 2019, the Philippines culled 20,000 pigs amid heightened fears over African Swine Fever (ASF)
spreading the country and affecting its 260-billion peso swine industry. Source: Xinhua
The unemployment rate was high during the COVID-19 lockdown from March to June 2020. Many
establishments were closed and PUJ’s (Public Utility Vehicle) ceased operations to control the
spread of the virus.

2. Deontology – is an ethical theory that uses rules to distinguish right from

wrong. It considers the way that things are done rather than focusing just on
the outcomes. It states that an act is not good morally can lead to something
good. This type of ethics holds at its core the respect for fundamental rights,
such as the right to truth, privacy, and the fulfillment of promises.

For instance, shooting the intruder to protect your family; killing is

wrong but protecting your family is right. This means protecting your family
is the rational thing to do even if it’s not the morally best thing to do.

Ethical Principles

Modern biomedical ethics is based on four factors: respect for autonomy,

beneficence, nonmaleficence, and justice, however, truthfulness and
confidentiality are included as it is basic to a relationship built on trust and
respect. Ethical principles are established rules for action or conduct in
relationships with others. These principles are set as the accepted standard in
terms of medical research.

1. Truthfulness and Confidentiality

Truthfulness is about telling the truth to someone who has the right to
know the truth. The concept of truthfulness in healthcare urges the
healthcare professional not to lie. For example, a physician has been
informed about the laboratory test result of a patient, the physician has to
tell his patient about the laboratory test regardless of the result.

Confidentiality is about privacy and respecting someone’s wishes. It

means that healthcare professionals shouldn’t share personal health details
with others unless that person has said they can or it’s necessary. For
example, if the family of the patient wanted to know about the laboratory
test result, the physician should not tell them, unless consent was given by
the patient to do so.
 Principles: Respect the patients’ privacy and be honest
in dealing with them.

2. Autonomy

Autonomy refers to every individual’s right to self-governance,

independence, and freedom to make their own decision. This makes the
person make a rational and uninfluenced decision. Therefore, it can be said
that autonomy is a general indicator of a healthy mind and body. Autonomy
is Latin for “self-rule”. This presents the obligation of healthcare
professionals to respect their patients’ right to make decisions about their
health.

Autonomy must be respected even as healthcare professionals do not

agree with the patient’s decision. This is also called the principle of human
dignity. It includes the duty not to interfere with the decisions of competent
adults, and the duty to empower others for whom we are responsible.

For example, an autonomous person is someone capable of making a

rational and informed decision on their behalf, but it does not mean that they
have the right to do whatever they want or disobey law and regulations.

Principle: Honor the patients’ right to make their own decision.

3. Beneficence

Beneficence is defined as an act of doing good to others like

charity, mercy, and kindness. This principle addresses the idea that a
person’s action is coupled with one’s moral obligation. Every healthcare
professional has the inherent moral imperative of doing right. It tells about
‘doing good’ for the patient, for instance providing immunization to prevent
infectious diseases or giving the least radiation dose to the patient. This
follows the ALARA principle, ‘as low as reasonably achievable’. Radiation is
not good for the body, but giving the least possible radiation to the patient
will be beneficial to get an accurate diagnosis.

Principle: We must take positive steps to prevent harm.

4. Nonmaleficence
 Nonmaleficence is an ethical principle that means doing no harm or
inflicting the least harm possible to reach a beneficial outcome. The
principle of nonmaleficence holds that there is an obligation not to inflict
harm on others. It is closely associated with the maxim (Latin phrase)
primum non nocere which means ‘first, do no harm’. Every healthcare
professional should not harm patients, for example, providing an
appropriate lead shielding to the patient during x-ray examination to
prevent unnecessary radiation exposure.

When combining beneficence and non-maleficence, it presents that each

action must produce more good than harm.

Principle: To “do no harm.”

5. Justice

Justice is an ethical principle that entails fairness, equality, and

impartiality. Healthcare professionals must be fair to all. There are two
categories of justice: distributive and social justice.

Distributive justice means that individuals have the right to be treated

equally regardless of appearance, race, ethnic origin, religion, social, and
financial standing. Every patient should be treated in the same way.

Social justice is the right to access and participate in all aspects of goods
or services provided in society, regardless of their social status. Everyone
should have access to the same things that might improve the patients’
health. Social justice captures the moral principles in advancing human
well-being by improving health and doing so particularly by focusing on the
needs of the most disadvantaged.

These two aspects of justice – health improvement for the population and
fair treatment of the disadvantaged – create a richer understanding of public
health.

Principle: To be fair and treat each case alike.

When combining beneficence and justice, every individual must work for the
benefit of those who are unfairly treated.
 Healthcare professionals not only must follow ethical principles but must
indeed “be” a virtuous agent- a professional characterized by moral excellence,
goodness, and righteousness. Ethical rules must be thoughtfully tempered by
the wisdom of virtue. Radiologic technologists must both appreciate the rules
and principles governing ethical behavior and be a person who is defined by
clear moral virtues such as prudence, integrity, and compassion.