Is 'medical ethics' an oxymoron?

Telling people that you work in the field of medical ethics usually brings on one of two general reactions (if you are lucky enough to get anything more than a disinterested shrug). A small minority says something like “thank goodness, it’s about time we started looking at medicine through the lens of ethics,” as though this is a wholly new enterprise, never before undertaken by humankind. The rest remark that the term seems like an oxymoron, along the lines of “working vacation,” “bittersweet” or “civil war.”

So, as a field of study, “medical ethics” is either wholly novel or conceptually impossible. Let’s consider the second of these possibilities first.

What is an oxymoron? An oxymoron is a figure of speech in which seemingly contradictory or incongruous elements appear side by side.

I taught Business Ethics at a Canadian university for over a decade and my first lecture of the year always started with the question “Is Business Ethics an oxymoron?” In asking this, I aimed to dismiss some common assumptions about what business and ethics are, and why they don’t need to contradict one another after all. 

I think most people assume that medicine and ethics, like business and ethics, are about as opposed as two disciplines could be. Medicine is scientific, precise, objective, and based largely on a system of authority. Ethics, on the other hand, is unscientific, imprecise, and just a matter of personal opinion. Or at least these are the common assumptions. How can you have an imprecise, subjective study of something scientific and objective? And if medicine really is such a precise, closed discipline, why does it need ethics, or ethicists for that matter? 

So, are “medicine” and “ethics” incongruous? Do they really contradict one another? 

Contrary to the common assumption, “medical ethics” has actually been with us for a very long time. The term first appeared in 1803 when the English physician Thomas Percival wrote Medical Ethics, a text which largely influenced the American Medical Association’s code of medical ethics, adopted in 1847.

But medical ethics is quite a bit older than this. 2200 years before Percival penned his book, the Greek physician Hippocrates wrote what has come to be known as the Hippocratic Oath, a code of ethical principles for doctors and their students.

And an unfathomable 1300 years before this, King Hammurabi issued the Code of Hammurabi which, among its 282 Laws, includes a set of instructions for the conduct of physicians, including the setting of professional fees, and the punishment of physician incompetence and negligence.

So if it is wrong to think of medical ethics as a discipline, if “medical ethics” really is an oxymoron, then it is an error we have been making for at least 4,000 years.

I want to suggest to you that this is not an error and that “medical ethics” is, and should be, as old as the practice of medicine itself. In fact, an ethical ‘sphere’ exists wherever and whenever medicine is practiced.

Why would this be? There are two main reasons, I think.

First, the practice of medicine involves the possibility of harm. This harm could come in the form of deception, manipulation, negligence or even physical assault. The doctor—patient relationship intractably involves a power imbalance: patients have needs that physicians, possessing specialized knowledge and skills, are uniquely able to meet. This is why the doctor-patient relationship is framed as a fiduciary relationship, a relationship of trust. As patients, we are vulnerable, not just when we are sick but when we are well since our health is fragile and needs to be carefully protected. Wherever there is vulnerability and the possibility of harm, moral transgressions are possible and ethics is not only appropriate but necessary.

Secondly, and perhaps more interestingly, is the fact that medicine and ethics have roughly the same aim even if the particulars of their disciplines look a little different. Medicine is the practice of helping humans to attain and maintain health in all relevant respects: physical, mental, emotional, etc. And, the Greek word that often gets translated as “virtue” is “arête,” or excellence, and is bound up with the notion of the fulfillment of purpose or function: the act of living up to one’s potential. So, whether we are talking about the integrity of a person’s body, mental life, or relationships with others, medicine and ethics both aim to maintain and perfect the things that matter most to us.

“Medical ethics” isn’t an oxymoron. It speaks to the very real concerns — autonomy, privacy, security of the person, promise-keeping, and the like — of very real people when we are at our most vulnerable. Many of these concerns will be the subjects of future columns. For now, the important point is that the practice of medicine is intractably ethical. 

The ethos of the last two years seems to have severed the relationship between medicine and ethics, unmooring us from a history that made us responsibly aware of all the ways we are capable of harming one another. We need to remind ourselves of our shared vulnerability and responsibilities to one another, especially when we enter the medical sphere.

Until next week,

Julie

Julie Ponesse, PhD

Ethics Scholar

The Democracy Fund