Answering Ethical Questions


Some of today's revolutionary medical procedures-organ transplants, test tube fertilization and gene therapy- have extended and enhanced life as never before. But they have also spawned difficult moral questions. What, if anything, should be done when in vitro fertilization results in a woman carrying six or seven live fetuses? Exactly how old is too old to become pregnant ? Fifty, 60, 65? Are the results of genetic testing really confidential? And who should get one of the precious few donor organs: the youngest patient or the sickest?

To help future physicians at UMDNJ-New Jersey Medical School (NJMS) prepare for such situations, they are offered a mini-series, "Ethical Issues in Medicine." The non-credit elective is problem-based and acquaints students with the principles and methods used to solve ethical problems in medicine. The six-week course also gives them a chance to explore some of the issues confronting physicians today.

Educator and ethicist Cynthia Stolman, PhD, an assistant professor in the Department of Pediatrics and co-chair of the Office of Medical Ethics and Law at NJMS, presents students with a variety of actual cases, some already decided in the courts and others still pending. Using the theories of ethics, students try to resolve the cases.

Four basic principles are reviewed: autonomy; nonmaleficence, or causing no harm; beneficence, or promoting good; and justice. "The principle of autonomy enjoins us to respect others' judgment," says Stolman. "Everyone who has decisional capacity has the right to choose whether to have, or not have, a procedure performed on themselves. You violate that right when you treat a person according to your own goals, without regard to the other person's goals."

But like all rules, there are exceptions. A person with TB, for example, is not given the choice of taking or not taking the treatment, since TB is a communicable disease and therefore a threat to others.

As an example of autonomy, the students are asked what they would do if asked, by the family, not to reveal the diagnosis of cancer to a patient. "If they learn nothing else," Stolman says, "students must learn to appreciate patients' rights. This is the most important principle and the basis of almost everything they do." She says it often takes a physician a lifetime to master patient autonomy. The principle of nonmaleficence is the basis of the Hippocratic tradition. Physicians are taught first to "do no harm." This principle answers the classic question of whether or not a doctor should participate in physician-assisted suicide."Very often the physician is torn," Stolman says. "He may personally condone suicide, but according to this principle, should not participate in it."

The principle of beneficence creates a positive obligation on the part of physicians to promote good. For example, helping other members of society, including future generations, is often cited as the justification for scientific research.

But sometimes, Stolman says, it's difficult to decide what is good. "In class we use the example of a patient who has Lou Gehrig's disease and tries to commit suicide with pills," she says. "As a physician, you save the patient's life. We ask the students if that's good for the patient." She says students then are asked to decide whose values they would be applying when resuscitating this particular patient.

Justice deals with the allocation of scarce medical resources. Should they be distributed according to need, social worth, ability to pay, ability to contribute to society or least able to help themselves? "Physicians are drawn into this problem, like it or not," says the ethicist. "Generally we follow the rule that goods and services are given to those who need them most, as long as it doesn't disadvantage others."

There are other principles as well, including ethical relativism, which states that what's right in one country may be wrong in another. The theory of universality states what actions are wrong or right on a universal scale. "This theory asks, 'If everybody did this or acted this way, would it work?'" says Stolman. "For example, if everyone lied, there would be no such thing as the truth. Therefore lying is a universal wrong."

She points out that ethical issues can be complex. "As a physician you must be comfortable with ambiguity," she says. "Usually experienced physicians are comfortable with the ambiguity of ethical dilemmas. But in many cases, helping families with life and death decisions is never easy."