Ethical Considerations in the Care of Patients with Neurosurgical Disease

Origins of Contemporary Medical Ethics

Western medical ethics is believed to have originated with the Hippocratic cult (about 450 to 300 bc ), a group of early physicians who are thought to have been heavily influenced by the Pythagorean thinkers. Rather than ascribing disease to be solely the province of supernatural or deistic causes, this group was responsible for one of the first systemized efforts to impart a naturalistic approach to the study and practice of medicine. In addition to their accomplishments in mathematics, the Pythagoreans developed a moral philosophy that emphasized respect for life. This outlook would account, for example, for the apparent strictures on abortion and euthanasia that are features of a prominent version of the Hippocratic Oath. For different reasons, the oath also prohibits surgery, which was not regarded as a proper part of a physicians’ activities. The attitudes held by the Hippocratic physicians apparently were not widely held among other physician cults of the ancient world.

The Hippocratic tradition urges physicians to “do no harm” and to use their skills for the welfare of the individual patient. For many years these principles were thought to justify medical paternalism because they seemed to generate duties that were mainly intended to minimize physical harm and to improve the patient’s physical well-being. Given that the physician possessed specialized knowledge of the physical structures and causal processes of the patient’s body, the physician and not the patient was considered most qualified to determine a patient’s health care goals and the means to achieving them. On the basis of this reading of the Hippocratic Oath, patients were not thought qualified to shape the course of their individual care because of their general lack of scientific insight into the nature and workings of their own physical condition.

The last 40 years or so have witnessed a trenchant and often passionate critique of the idea that a patient’s best interests are limited to or exhausted by his or her physical wellbeing. Because a patient’s best interests must be determined in light of his or her values and life goals and because the value a patient places on physical well-being depends on how it fits within this larger framework of values and projects, the competent and well-informed patient is generally recognized as the best judge of appropriate health care goals. Few would deny the accuracy of the Hippocratic conception of medicine as a science whose goal is the health and physical welfare of the patient nor challenge the claim that physicians must always look after the best interests of their patients. However, the fact that a competent patient lacks specialized medical knowledge is generally recognized to be less important than the fact that each patient is the most qualified judge of the relative value of his or her physical well-being in relation to his or her larger life goals and projects. For this reason, patient self-determination, as well as its culmination in the doctrine of informed consent, represents the bedrock of contemporary clinical ethics.

As medical science has progressed and physicians have developed the ability to alter the course of a person’s life with the use of an array of medical technology, patients have taken a greater interest in determining the way their lives should be shaped. The early seeds of patient self-determination and the doctrine of informed consent began developing as early as the latter part of the 19th century. This period and the early part of the 20th century saw many legal cases involving surgical patients whose consent to excision of tissues had not been obtained. Under prevailing legal theories, these actions were at first considered torts, such as battery or “unconsented touching.” As medical and judicial systems evolved, they were then gradually brought under a negligence theory. This change strengthened the growing expectation that informing a patient of the reason for the procedure and obtaining consent for it were proper parts of the physician–patient relationship. In theory, at least, obtaining the patient’s informed consent became an essential aspect of the developing standard of care. However, honoring this legal requirement in clinical reality awaited the increased attention to ethical issues that emerged in the late 1960s.

Although we focus here on clinical ethics, no survey of the history of medical ethics can omit society’s reaction to the abuses of human beings perpetrated by physicians and scientists in the concentration camps of Nazi Germany. The revelations at Nuremberg led to the promulgation in Helsinki and Geneva of international standards for the protection of research subjects. Unfortunately, these efforts did not prevent blatantly unethical practices in the context of subsequent research by American investigators. As a result, strict statutory protections were established to ensure the informed consent of research participants, including protocol review by institutional committees. Public recognition of research abuses led to heightened scrutiny of the physician–patient relationship in the clinical setting and greater support for the concept of informed consent.

Technologic advances once again profoundly influenced the direction of medical ethics, beginning in the later 1960s with the arrival of practical artificial respiratory equipment and, in the early 1970s, with the development of materials that facilitated artificial hydration and nutrition. These advances—combined with social and political changes, including the civil rights movement—culminated in the celebrated legal case of Karen Ann Quinlan in 1976. In the Quinlan decision, the New Jersey Supreme Court established that the right to refuse medical treatment was fundamental and could be exercised on behalf of an incompetent patient by informed surrogates who were knowledgeable about the patient’s previous values and lifestyle. The family was found to be in the best position to represent the wishes of their close relative.

In summary, the history of Western medical ethics has featured a transition from the “beneficence” orientation (doing good for the patient) of premodern medicine to the view that the patient must ultimately decide what his or her best interests are after going through a process of informed consent. Both morally and legally, patient self-determination has become the gold standard of modern biomedical ethics. In the next section, we review the prevailing philosophical principles and theories that are often used to further assess ethical problems in modern medicine.

Prevailing Theories and Principles

The term medical ethics, as it is used in contemporary society, is somewhat ambiguous. It may refer to those rules of conduct established by the formal bodies of the medical profession in the course of regulating itself, such as the prohibition of the sexual exploitation of one’s patients, or it may refer to novel ethical dilemmas that actually confront health care workers and have no obvious solution in terms of traditional values and ethical codes, such as the removal of life-support systems from irreversibly comatose patients.

Two philosophical approaches dominate the literature. Tracing its roots to the German philosopher Immanuel Kant (1724–1804), the Kantian tradition holds that people have a fundamental right to be treated as ends in themselves and not merely as a means to some other end. The basis of the Kantian view is that each person has the capacity to take on projects and to give a distinctive shape to his or her own life. This capacity must be respected in each individual because the value of all other things is derived from the exercise of this capacity. Patient self-determination and informed consent are, therefore, the preeminent Kantian values for clinical ethics, because without them we cannot freely set the ends for ourselves that give all other things their moral worth. As such, they represent the necessary conditions for treating a patient as an end in himself or herself.

Utilitarianism traces its roots back to the English philosophers Jeremy Bentham (1748–1832) and John Stuart Mill (1806–1873). Utilitarianism is a form of consequentialism, which holds that actions or policies are right in proportion to the extent to which they promote the aggregate happiness or well-being. Whereas the Kantian can claim that physicians have special duties to their patients, which derive from the need to respect their patients as ends in themselves, the utilitarian must argue that any duties physicians owe to their patients are rooted in the fact that fulfilling those duties maximizes overall happiness.

Although the principle of autonomy is commonly regarded as the first principle of contemporary medical ethics, those with a more utilitarian slant believe that it is conceptually balanced by the principle of beneficence; the obligation to do good for the patient. Beneficence is closely associated with the traditional Hippocratic obligation to at least not harm the patient, or the principle of nonmaleficence. Arguments that establish the moral basis of beneficence and nonmaleficence are available both to Kantian and utilitarian theories. The main difference between these theories, therefore, lies not in the principles they recognize but in the way they justify those principles and the way they order them in relation to one another.

The Provider–Patient Relationship