Medical Ethics and Decision Making Do Doctors

Medical Ethics and Decision Making

Do Doctors Need More Guidelines?

New Revolution in Ethics

In 1988, what many called the 'third revolution' in medical care came about (Dunevitz, 1999). The first revolution was after the Second World War, and this caused an explosion in the number of hospitals and doctors, as well as the research that went into the field (Dunevitz, 1999). Medicare and Medicaid were created and the field of medicine was growing so rapidly that it was hard to follow it and understand everything that was happening to it (Dunevitz, 1999). In the 1970's, cost and how to contain it became more of an issue than the growth of medicine and not only employers but the government began to work against the costs that were getting out of control (Dunevitz, 1999).

This caused the creation of managed care, among other measures (Dunevitz, 1999). Even though the control of these costs was very important, there came a time where it became difficult to judge the quality of care that many patients were receiving and this led to the third revolution - accountability and assessment (Dunevitz, 1999). The purpose of this literature review is to discuss the revolution of accountability and assessment, and what it means for doctors in the UK and in America. While the UK should be the main focus, America has many problems with the same issue and much of the information to be found on the subject deals with America. Other information is largely universal, as doctors everywhere must deal with ethics, guidelines, and responsibility to their patients (Dunevitz, 1999).

The significance of this is very great and should not go unnoticed (National, 1980). Looking at the chronology that was just mentioned above helps to create an understanding of how accountability became so important in the medical profession and why it still remains one of the most important issues that all doctors, hospitals, and insurance companies must consider (National, 1996). In the new era of health care, the assessment of quality occupies an important area, especially when it comes to delicate and often controversial topics such as abortion, plastic surgery, difficult diagnoses, and assisted suicide (Witkin, 2000).

While some of these topics are more controversial than others, all of them are within the realm of concern for doctors and hospitals, and whether more guidelines for these issues are needed is a focus of concern for almost all countries of the world (Denhardt, 1991). This is especially true in the more developed countries where there are more options and freedoms when it comes to medical care that is sometimes not necessary but is chosen by the patient for various reasons (such as in most abortions or plastic surgery cases) (Kutchins, 1991).

The Importance of Quality

In addition to this quality assessment, quality improvement has become increasing important (Kleinman, 2001). It is now not enough to look at something and determine whether quality is present (Kleinman, 2001). Now, if the quality is not present that must be corrected, so that quality can be created where there previously was none, and so that quality can be improved where it previously was low (Kleinman, 2001). This idea of quality has become fundamental to health care and is not something that is going to be diminishing as time goes on (Kleinman, 2001). The rising costs of health care, both in the UK and abroad, are causing many to reconsider some of their health care options and are forcing many to go without insurance (Kleinman, 2001).

Many countries have government plans that can help those that are most in need, and some also have insurance plans that cover everyone, regardless of their income, class, or status, but even these programs have their flaws (Kleinman, 2001). Some individuals may not see this issue as having ties to quality, but it does (Kleinman, 2001). For example, there are concerns in many countries that those who receive government assistance for health care do not get the same respect and the same quality of care as those that have more money and have private insurance. The same concern is expressed for those that have HMOs, PPOs, and other health care plans that are not the same as private insurance (Kleinman, 2001).

Unfortunately, private insurance and the high quality of care that originally came with it is dwindling and many people cannot afford to have it (Daley, 1999). Most of those that have it are those that are retired and were fortunate enough to have good jobs through strong companies that continue to pay their insurance premiums (Cohen, 2001). There are fewer and fewer of these people every day as the populations ages and more companies stop offering these kinds of benefits to their workers and retirees (Mattison, Jayaratne, & Croxton, 2002).

One of the reasons that doctors and hospitals are struggling with the quality area of the health care issue is that there are many other issues that they must deal with, and they face increasing pressure to raise their rates and treat patients only for what they absolutely need because their health care plans will not pay for anything that might cost extra (Mattison, Jayaratne, & Croxton, 2002).

Even if extra tests or medications are important, many doctors cannot even tell their patients about them if they know that the patient's health care plan will not cover the cost (Mattison, Jayaratne, & Croxton, 2002). This is not quality, but it is what is happening to much of the world (Mattison, Jayaratne, & Croxton, 2002). There is a huge battle going on at present between cost and quality, and it seems that cost is winning (Mattison, Jayaratne, & Croxton, 2002). However, quality has begun to fight back and there is hope yet that health care can be adjusted so that doctors and hospitals will once again be able to provide the high quality of care that they gave in the past, without fear of reprimand or low payment (Mattison, Jayaratne, & Croxton, 2002). Another concern with the health care problem is that it is arguable as to what makes something 'good quality' (Mattison, Jayaratne, & Croxton, 2002).

It can be a good value for the money, lead to increased longevity, lead to a better quality of life, and many other things (Langs, 1976). Agreeing on a concise and concrete definition of quality healthcare is a sticking point for many, and until a way of determining the quality of health care can be created it is difficult to compare it to the current quality of health care in order to see if the two match up or where improvements need to be made (Bok, 1980). By creating an assessment that will allow this comparison to be made, the next step will be taken toward making sure that good quality health care is something that is available to all and that standards of care are kept high for all who need medical assistance (Campen, & DiLoreto, 2000).

Guidelines, Accountability, and Rapid Expansion

It will also help to show the guidelines that may be needed where delicate and controversial topics are dealt with because many doctors are better than others at concepts such as 'bedside manner' (Davies, 1999). While there are some that feel this is not as important as the treatment or medication that is received, it is part of the notion of quality and therefore it becomes important to the patient (Victor & Cullen, 1997). What is important to the patient should therefore be seen as something that is important to the doctor and the hospital, but this is too often not the case with many medical professionals (Taylor, 1999).

To some degree, this is not their fault. When health care was expanding so rapidly many medical professionals put their time into research that would benefit future patients, and this was undoubtedly important (Kanuha, 2000). When cost containment begin to be seen as problematic, many medical professionals devoted much of their time to concerns about how they could lower the costs, both for themselves and their patients (Goold, 2001). Unfortunately, there was no time taken when all of this was going on for doctors and hospitals to focus on the quality of care that their patients felt they were getting (Goold, 2001). Now, quality has become a large issue and many medical professionals are unprepared because they were not trained for it (Goold, 2001).

They were trained to research and figure out how to help more people with new scientific advances, and when needs changed they were trained to deal with costs and financial information, but they were never trained to deal with the actual quality of care that they were providing to their patients (Goold, 2001). This does not mean that they did not concern themselves with whether their patients got better or not, but only that they did what they could for their patients based on the guidelines that were available through the patient's health plan and knew that they must leave it at that because they would not get paid for anything else (Goold, 2001). Doctors are often conflicted emotionally by this because their ethics and morals conflict with what they can do for their patients (Goold, 2001).

It is becoming more clear that doctors need more guidelines when it comes to delicate situations involving their patients, because they often have to go on only what they are taught in medical school and do not get to exercise their ethical beliefs as much as they would like (Rhodes, 1986). In other words, they often do not have the power to try to help their patients in the best way possible because they are unaware of some of the options that they have or are not able to find a way to get the procedure, tests, or medication covered by the health plan that the patient has (Stromwall, 2002). Concern for cost is, of course, important, but quality is more significant, and balancing these two issues fairly and completely is something that must be dealt with when the quality assessment and quality improvement issues are studied (Cox, 2002).

One of the most important issues, however, when it comes to quality and patient care, has to do with accountability (Doherty, 1995). Doctors are generally accountable to the hospital that they are associated with, and to the governing board that issued their medical license (Estroff, 1995). The changing regulations that are being considered when it comes to quality will have the doctors finding themselves accountable to the patients as well, and to other consumers such as potential patients and employers that are considering a company health plan (Faulkner & Faulkner, 1997). This is very significant because doctors will have much more to consider when it comes to their beliefs and opinions about quality health care and how best to provide it (Faulkner & Faulkner, 1997).

Some of the things that could be provided to consumers include mortality rates and information collected from surveys about patient satisfaction (Faulkner & Faulkner, 1997). This information could be important for those deciding which doctor they want to make their own (Faulkner & Faulkner, 1997). Important to this is the long-held belief that the doctor knows best and the patient should simply do what he or she is told (Faulkner & Faulkner, 1997). Now that more people are taking charge of their own health care and learning about their conditions and symptoms, more doctors are finding that what they have to say is being questioned (Faulkner & Faulkner, 1997). Some welcome this, as it helps them to keep up with what is going on, but others feel as though their abilities and decisions are being questioned, and they are often uncomfortable with patients who appear to know more about certain medications and conditions than the doctors themselves (Faulkner & Faulkner, 1997).

These doctors could learn much from their patients, but they choose not to, and whether their behavior is ethical or moral, it certainly does not help them or their patients to learn more about what they need to protect their health and livelihood (Faulkner & Faulkner, 1997). Coming along with the quality concerns is the issue of patients' rights (Irving & Young, 2002). Patients' rights became big several years ago when increasing numbers of patients began to think that perhaps they were not getting everything that they should at their doctor's office, and many of them were disenchanted with the treatment that they were receiving (Faulkner & Faulkner, 1997). Applying patients' rights and quality assessments to medical ethics and morals is something that is relatively new, but it has sprung from patients' rights complaints of the past and the concern for quality assessments and improvements of the health care system in general (Faulkner & Faulkner, 1997).

Controversial Issues and Ethical Behavior

Both of these causes, as has been mentioned, have their own individual degrees of importance (Hartman, 1993). However, when they are combined they are very powerful, and doctors, hospitals, and others in the medical profession have not been able to ignore them (Hartman, 1993). This has been especially true in areas such as abortion and assisted suicide (Hartman, 1993).

These areas are already having their own difficulties because of the controversy that surrounds them, and this controversy is made stronger when doctors have difficulties with them due to ethical and moral beliefs and opinions (Hartman, 1993). Peer pressure, family attitudes, and religious views can all affect how a particular doctor feels about his or her practice and the procedures that he or she is asked to perform (Hartman, 1993).

Generally, doctors that have objections to a particular procedure, such as abortion, will not undertake any type of medicine where this may be necessary, but sometimes they are asked to perform a service or recommend someone who can, and their moral and ethical beliefs can affect the decision that they make for their patient (Hartman, 1993). There is some concern about this, as different doctors share different opinions and beliefs, and they must do all that they can for their patients but ensure that they do what they feel is morally right, as well (Hartman, 1993).

Sometimes, these things conflict and when they do the doctor has trouble finding a happy medium between what he knows he should do for the patient and what he feels is right morally, ethically, and religiously (Hartman, 1993). The question then arises as to whether there should be more guidelines for these doctors to follow (Hartman, 1993). Having more guidelines for these sensitive issues will help these doctors to be aware of what they must do and how they can reconcile these requirements for their practices with what they believe in (Hartman, 1993).

Until recently, there has not been much interest in using the assessment and improvement techniques that come with quality to deal with ethics and morals, because these things are thought to be personal and not something that the medical community can be forced to impose regulations over (Hartman, 1993). However, when something affects the health of the patients, then it becomes the concern of the medical community and must be dealt with accordingly (Hartman, 1993). This concern for ethics expands not only to doctors, but also to hospitals and health care plans, as they are all involved in the ethical and moral dilemmas that are sometimes faced and in the care of the patients that they deal with (Hartman, 1993).

There are some that wonder why anyone should be so concerned about using quality assessment for medical ethics and accountability, but it has become a very large problem for many patients, and as an extension of that, a problem for doctors and other medical professionals (Hartman, 1993). It has gotten to such a point that something must be done to correct it. The real answer to that question of 'why?', however, lies in the field of bioethics and how much it has progressed since the Second World War (Hartman, 1993). Those that work in the field talk of the rights of patients, but the field has been very slow to insist on changing anything regarding its behavior and has not given any kind of accountability for the quality of their ethics practices to consumers (Hartman, 1993).

Bioethics

There are many aspirational standards for those in the field of bioethics, and those who work in that field usually work toward those standards instead of looking at their actual behavior from an ethical standpoint and looking for ways to change their profession so that ethics is not such a large concern as it currently is (Freedman & Combs, 1996). These high standards are still important today, but recently some in the field have begun to see that legal requirements and enforcement are also highly important (Fitzgerald, 1989). Much of this applies to what is now being done with experimentation, cloning, and other highly controversial procedures, but there are also applications to some of the more accepted but still controversial issues of the day, such as assisted suicide, abortion, and plastic surgery (Hartman, 1993).

Where assisted suicide, also sometimes called euthanasia, is concerned, there is not as much need for discussion because there has not been as much acceptance of the practice (Hartman, 1993). Ethics are still a concern for this issue, but the lack of acceptance has made assisted suicide something that is not often discussed and is not widely practiced (Hartman, 1993).

Based on this, there have not been serious demands about ethical guidelines for the practice, other than to argue whether the practice itself should be considered ethical when the goal of the doctor should be to prolong life, not find a way to help end it (Hartman, 1993). However, those that believe in assisted suicide argue that a good death is often more important to a terminally ill patient than a prolonging of a life that is painful, uncomfortable, and will undoubtedly end soon anyway (Hartman, 1993). The feelings and beliefs of the doctor have much to do with whether he or she agrees with assisted suicide or whether he or she is convinced that it is wrong (Hartman, 1993).

These beliefs and opinions can come from many things, including peer pressure, family attitudes, and religious views (Hartman, 1993). How someone was raised and the values that he or she grew up with play a large part in that person's determination of what is ethical and what is not, and the opinions of other doctors in the field can also cause an adult form of peer pressure that some people will succumb to (Hartman, 1993). Often, the religious views that a particular doctor holds will have the most to do with whether he or she feels that something is ethically or morally acceptable (Hartman, 1993).

There are many different religions, and although Christianity seems to be predominant in many Western countries, there are various branches of Christianity that hold different views about death, abortion, and even plastic surgery (Hartman, 1993). Along with this, there are doctors who do not practice Christianity in any form, and these doctors have still other beliefs and opinions that they must incorporate into their practices (Hartman, 1993). They find ways to justify what they do, or they choose not to do it, and they must balance what they believe in with what is right for their patients (Hartman, 1993).

Turning from the topic of assisted suicide, there are many other issues that are worthy of a discussion of ethics. Plastic surgery and abortion are the most significant of these, because there are the ones that appear to occur most frequently (Hartman, 1993). Both are generally accepted by most people, or at least recognized as part of society and an individual choice, but there are still many that believe abortion is wrong and there are also some that believe even plastic surgery is unacceptable behavior and unnecessarily dangerous for reasons that often involve nothing but vanity (Hartman, 1993).

However, there are women who must have abortions due to health, and there are people who need plastic surgery for burns, disfigurements, and other problems that have nothing to do with being vain (Hartman, 1993). These are areas where ethics and accountability sometimes have problems, and where doctors that hold specific beliefs often struggle with what they feel is right and what they really should do (Hartman, 1993).

Determining ethical behavior is difficult for another reason, which is that there are many different viewpoints of what is ethical, and patients that have no objection to a procedure might be followed by patients that do object (Goldstein, 1999). This objection by the latter patients does not necessarily make the procedure unethical, any more than the lack of objection by the former patients makes it ethical Freud & Drug, 2002). What is ethical must be determined some other way than what the patient agrees with, but how to make that determination is causing healthcare workers a great deal of stress and concern, and much of this is being transferred to the patients (Hartman, 1993).

There is no way that a doctor can please everyone all of the time, even with the most polite and respectful bedside manner (Kagle & Giebelhausen, 1994). There will always be someone who is unhappy with their treatment, unhappy with their diagnosis, wants to seek a second opinion, or does not like a particular doctor because of what he or she did for another person, among many other concerns (Jacobson, 2001). This problem is far-reaching and does not belong only to the UK, or to America, or to any other country (Hartman, 1993). It belongs to all of the world and all of the medical community in developed countries where there are rules, regulations, and laws about medicine and how it can be practiced (Hartman, 1993). For these countries, ethics and accountability in the face of higher health care costs have become big issues (Hartman, 1993).

Informed Consent

One of the first ethical issues to be addressed was that of informed consent (Hartman, 1993). In other words, the patient or potential patient must be made aware of the procedure or medication and must understand what it is for and what possible side effects may be present (Hartman, 1993). Without being aware of this, there is little chance that the patient will have a full understanding of some of the problems that could be encountered (Hartman, 1993). Even if the problems are rare, they must be mentioned, so that patients will know if they are experiencing difficulties that might be related to a procedure or to a medication that they have been given (Hartman, 1993). This was largely designed for patient protection and to avoid lawsuits, but it also falls under the concept of ethics (Hartman, 1993).

It is important to discuss informed consent, but it is also important to look more closely at it in the area of bioethics, because it is a field that has stirred up much controversy and continues to do so as the field expands into more serious and significant areas of experimentation (Hartman, 1993). In the 1970s and 1980s, there were many studies done about bioethics, and they looked at the disclosure that was offered to patients (Hartman, 1993). They also examined the decision-making capacity that the patients had, how much the patients understood, and how voluntary their decisions actually were (Hartman, 1993). All of these things were important, because they indicated to what degree the doctors were actually explaining things to their patients and making sure that they understood before they consented to any kind of procedure or medication that they were asked to agree to during their appointment (Hartman, 1993).

One of the most significant findings of an analysis of these studies was that there were areas of consent and disclosure that had no studies done about them (Hartman, 1993). Even though the doctrine designed to ensure that all patients knew about informed consent had been around for 25 years, there was little in the literature about how it worked or whether it was working well (Hartman, 1993). Naturally, this was not good for the medical business, and there was much upset in the researching community when it was discovered that there was a very large gap in the literature when it came to informed consent (Hartman, 1993).

This points to two different things. First, it indicates that not enough information had been acquired about informed consent and whether it was actually working (Hartman, 1993). Second, it indicates that there is no information as to whether any of the information that had been collected was put to good use in determining the problems that were inherent in the doctrine of informed consent and working to fix them (Hartman, 1993). Both of these points should be of great concern to doctors and others in the medical profession, as they indicate a lack of concern for patients that started some time ago and is apparently continuing into the present day (Hartman, 1993).

This is especially true with regard to the fact that there have been results of some studies published in medical journals but yet none of the information from them have been passed on to the average consumer (Hartman, 1993). Continuing in this way keeps doctors and others in the medical profession from having any accountability when it comes to ethics and decisions that these medical professionals must make (Hartman, 1993).

This hurts the medical profession because these doctors and others lose their credibility, and it hurts the patients because they must fight their way through a lot of information that they are now being given but still do not know really what to do with (AANE, 1999). Informed consent is such an important concept but it is often taken lightly in that there is not enough written about it and not enough of the information that has been written about it is used to actually help patients and improve the quality of their experience when they must see their doctors and have procedures performed (Bartle, Couchonnal, Canda, & Sraker, 2002).

History of the Issue

As far back as the 1960s, there was literature written on treatments and experimentation, and the ethical issues that result from them (Bartle, Couchonnal, Canda, & Sraker, 2002). The reason for this was the ethical scandals that began to appear in various experiments (Bartle, Couchonnal, Canda, & Sraker, 2002). This included not only the Tuskegee Syphilis Trials, but also experiments where retarded children were intentionally infected with hepatitis and other individuals were injected with cancer cells to see what would happen and whether these individuals would actually acquire cancer (Bartle, Couchonnal, Canda, & Sraker, 2002). None of these individuals had been advised as to what was happening to them, and they had not given consent for this type of experiment (Bartle, Couchonnal, Canda, & Sraker, 2002). Because of this, there were serious allegations made when it was found out what had been done, and the scandals increased (Bartle, Couchonnal, Canda, & Sraker, 2002).

Still, not all researchers were punished for the things that they had done, and there were few sanctions placed on any of them (Bartle, Couchonnal, Canda, & Sraker, 2002). This indicated that there was a serious lack of concern for the welfare of patients, and that the moral and ethical opinions of doctors and researchers were not strong enough to stop them from inflicting innocent people with chronic and often life-threatening diseases (Bartle, Couchonnal, Canda, & Sraker, 2002). These atrocities were committed over many years and the punishment that should have come from them largely never materialized, which left many to wonder whether the medical establishment had any morals and ethics at all, or whether they saw people as disposable (Bartle, Couchonnal, Canda, & Sraker, 2002).

Now, experiments are conducted with full disclosure and all people who are involved with them must know everything about what could happen to them if they agree to a particular procedure or medication (Bartle, Couchonnal, Canda, & Sraker, 2002). When all of the scandals first came to light, however, it did not immediately cause the changes that most people would have hoped for (Bartle, Couchonnal, Canda, & Sraker, 2002). Instead of changing the way that experiments were conducted because of the scandals that they were dealing with, mostly the scandals were written about and talked about (Bartle, Couchonnal, Canda, & Sraker, 2002; Barker, 1992).

It was pointed out that consensus was needed for all of those that were involved in experimentation and that subjects should have the freedom to withdraw from the trial if they did not feel comfortable, regardless of the importance of the research (Bartle, Couchonnal, Canda, & Sraker, 2002). It is interesting to note, however, that not only did these scandals not immediately change the way that experiments were conducted, but guidelines were necessary for medical ethics, instead of finding that the doctors and researchers felt that things were morally unacceptable (Bartle, Couchonnal, Canda, & Sraker, 2002).

As early as 1954, books were written that dealt with medical ethics, and there was an indication that some believed that medical ethics should be subjected to outside scrutiny, instead of just left up to the doctors and their discretion (Bartle, Couchonnal, Canda, & Sraker, 2002). This was important because everyone feels differently about what kind of behavior is ethical and moral, and due to this there are concerns that one doctor might have less of an ethical attitude about various treatments than another doctor, and one patient might feel more comfortable with a particular doctor and his attitude toward experimentation than another patient would (Bartle, Couchonnal, Canda, & Sraker, 2002).

More books were published in the late 1960s and early 1970s that dealt with seeing patients as people and with respecting their individuality, race, gender, and many other things that some doctors were previously not considering (Bartle, Couchonnal, Canda, & Sraker, 2002). The Hastings Center was also founded, and it began to publish reports and create studies that dealt with patients' rights and the ethics and morals that appeared to be lacking in many doctors and hospitals, but still very little was actually done to create guidelines and rules that would make doctors accountable for what they were doing (Bartle, Couchonnal, Canda, & Sraker, 2002). The point was not to instill morals and ethics into doctors, because most people develop those opinions themselves, but instead the point was to determine what kind of guidelines should be required to ensure that doctors, whatever their own beliefs and opinions, conformed to the rules that had been created for their profession (Bartle, Couchonnal, Canda, & Sraker, 2002; Strom-Gottfried, 2000).

It was not until 1973 that anything was actually proposed that would create guidelines to protect human subjects in experimentation (Spencer, Mills, Rorty, & Werhane, 1999). This was an important step, but it still did not protect all patients in general from the ethical and moral opinions of their doctors (Spencer, Mills, Rorty, & Werhane, 1999). A patients' bill of rights was also established in 1973, and many thought that it would do a great deal to help patients (Spencer, Mills, Rorty, & Werhane, 1999). However, there were no real penalties or way of enforcing the new bill, and because of that it became only a piece of paper that really had very little to do with what was actually going on in the real world of doctors, patients, and health care (Spencer, Mills, Rorty, & Werhane, 1999).

Another concern that came to light in the 1970s and 1980s, when all of this talk of patients' rights was being dealt with, was the fact that there was almost no input from those that should have mattered most - the patients (Spencer, Mills, Rorty, & Werhane, 1999). Doctors, researchers, committees, federal agencies, and all sorts of other governing bodies discussed the problem, talked about possible solutions, and came up with ideas of how these solutions could be implemented (Spencer, Mills, Rorty, & Werhane, 1999). Interesting enough, however, there was a strange and obvious lack of patient input in this process, which prompted some to wonder whether the patients were actually being considered and treated fairly when it came to creating a bill of rights for them and guidelines and rules that doctors would be required to follow (Spencer, Mills, Rorty, & Werhane, 1999).

There were also grass roots patient movements during that time in history as groups of patients fought back against some of the things that had been done to them, information that they were not allowed to be given, and problems that could occur in the future because of what doctors were doing today (Chase, 1996). Patients wanted to know how they could find out if their hospital had an ethics committee, what kind of ethics policies their doctor had, and other information along those same lines (Christopher, 1996). Unfortunately for the patients, their struggle was often in vain (Spencer, Mills, Rorty, & Werhane, 1999). There were many others that allegedly fought for the rights of the patient, but there was little that was actually accomplished during that time, and it appeared that no one was actually stopping to ask the patients what it was that they really wanted and needed (Spencer, Mills, Rorty, & Werhane, 1999).

The main goal of the grass roots movements that involved patients was to get control away from the doctors (Jayaratne, Croxton, & Mattison, 1997). However, that was often much easier expressed than actually accomplished, because most doctors resented having their control lessened and their opinions questioned (Spencer, Mills, Rorty, & Werhane, 1999). While this is not the case with many doctors today, it is something that has plagued the medical profession for a long time, and still does in some areas (Spencer, Mills, Rorty, & Werhane, 1999).

Law v. 'Common Sense'

Another argument that comes to light when discussing this issue is that ethics has to do a great deal with aspirational standards and by responding to this particular behavior and trying to change it to enforcing standards or other guidelines is actually something that belongs to the rule of law (Jacobson, 2001). This, however, often confuses the message that these individuals are trying to convey (Spencer, Mills, Rorty, & Werhane, 1999). There are many different ways that ethical obligations are communicated with different individuals and there are many ways to enforce these against professional people such as doctors, including using sanctions (Gabbard & Lester, 1995). However, there are also other ways to look at law in the service of ethics (Spencer, Mills, Rorty, & Werhane, 1999).

For example, beginning in the mid-1970s and working its way into the 1980s there were quite a few courts that utilized the help of various hospital ethics committees (Spencer, Mills, Rorty, & Werhane, 1999). Some states in America even require that hospitals have ethics committees based on state statutes or regulations (Spencer, Mills, Rorty, & Werhane, 1999). These ethics bodies were all created by various laws and they were all considered to have an advisory capacity (Spencer, Mills, Rorty, & Werhane, 1999).

Even as bioethics began to broaden its realm, however, there was still no specific interest in medical ethics that had any real weight with various courts and laws (Spencer, Mills, Rorty, & Werhane, 1999). Those who claimed to be ethics experts and provided testimony for various cases were often seen as not having a great deal of concrete evidence with which to present their case and there was quite often a great deal of confusion about the testimony that these individuals gave (Spencer, Mills, Rorty, & Werhane, 1999).

The committees that were created for ethics remained advisory only and they had no specific requirements or standards which were utilized to govern them (Spencer, Mills, Rorty, & Werhane, 1999). Informed consent is one of the most difficult issues to deal with in this regard because it has never actually been fully translated into any type of specific law (Spencer, Mills, Rorty, & Werhane, 1999). It remains an ethical mandate and while that this is important, it does not allow for the easy prosecution of individuals who do not see informed consent as something that they must be required to follow (Spencer, Mills, Rorty, & Werhane, 1999; Nava, 2001; Reamer, 1998; Specht & Courtney, 1994).

The Strongest Cases

There are many persuasive arguments made about the informed consent law and how it has never actually provided enough support for the autonomy of patients (Russell, 1984). There are many different rights that can be discussed when talking about patients and the most successful right that has been upheld within the courts is the rejection of life-sustaining treatment (Rose, 2000). This is not the same as the physician-assisted suicide, where the individual conscientiously decides to take his or her own life with the help of medical advice and authority (Spencer, Mills, Rorty, & Werhane, 1999). Instead, this applies more to the do not resuscitate orders that individuals sometimes give when they do not want anyone to take any heroic measures should they go into cardiac or respiratory arrest or become brain dead as a result of accident or age (Spencer, Mills, Rorty, & Werhane, 1999).

These cases have been the most successful but there are still problems with translating the rights that these individuals have received into any type of action (Spencer, Mills, Rorty, & Werhane, 1999). Much of this has to do with the fact that many of these patients died before the final judgment was ever rendered in the case and therefore this made the judgment completely useless to that particular individual (Spencer, Mills, Rorty, & Werhane, 1999).

It may possibly be considered to help others in the future, but it did nothing for the patient who originally brought the case to court (Spencer, Mills, Rorty, & Werhane, 1999). The same problems were often found with a similar issue, called advance directives (Spencer, Mills, Rorty, & Werhane, 1999). Most of these are termed living wills and they are created when individuals feel that they want their dying wishes understood and honored (Spencer, Mills, Rorty, & Werhane, 1999).

Instead of simply honoring these living wills many ruling bodies determined that there should be protections for terminal patients but had difficulty defining what terminal meant (Spencer, Mills, Rorty, & Werhane, 1999). Because of this, many of the living wills that individuals had created were seen as inappropriate or not acceptable under current law and therefore could not be utilized (Spencer, Mills, Rorty, & Werhane, 1999). Whether assessment of quality as it relates to ethics is actually feasible is another question that many individuals have addressed (Spencer, Mills, Rorty, & Werhane, 1999).