essay on ethics in medicine

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What is the place for philosophy within the field of medicine? A review of contemporary issues in medical ethics

• Richard Fenton   ORCID: orcid.org/0000-0001-5088-1991 1  

Philosophy, Ethics, and Humanities in Medicine volume  13 , Article number:  16 ( 2018 ) Cite this article

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This extended essay seeks to unpack some of the key aspects of philosophy which are applicable to medical thought and practice. It proceeds via an analytical discussion of the contemporary debate in three key areas of medical ethics: euthanasia, concepts of health & disease and psychiatry.

The main claims are as follows:

The case for legalising euthanasia is strong on philosophical grounds but there are numerous practical obstacles.

Elements from the normative and naturalistic definitions of disease are necessary for a thorough definition that dodges common objections to either.

Mental health cannot be subsumed under a purely physicalist model of health rendering it distinctly different from other fields in Medicine.

Through a detailed discussion of three salient issues in the philosophy of medicine, it is argued that the application of profound philosophical thought to medicine and its practices reveals a depth that necessitates exploration before simply following the aims of curing all. Philosophical rigour matched with modern medicine has the potential to engage patients and help them make independent, informed decisions and assist physicians to think more clearly, analytically and empathetically.

This extended essay seeks to unpack the key aspects of philosophy which are applicable to medical thought and practice. Philosophy can broadly be defined as ‘the criticism of assumptions’ [ 1 ] in the quest to clarify thought and solidify the foundations of knowledge. In the Western tradition this is typically achieved by an orderly dissection of the individual assumptions inherent to a particular body of knowledge; highlighting these assumptions, subjecting them to relevant objections and examining the validity of counter-examples makes up the bulk of most philosophical discussion. Thus, Philosophy within Medicine has far-reaching applications spanning such topics as subjective wellbeing, bioethics, scientific method and psychiatric illness to name but a few. The essay will proceed in three sections:

Euthanasia: The most immediate field for fruitful philosophical thought within Medicine, and the one most frequently encountered by medical students, Footnote 1 is the vast subject of Bioethics. Commonly, a scenario is recounted or devised which places dearly held ethical principles in conflict, demanding a resolution. Since an individual’s intuition alone is insufficient to rationally prefer one course of action over another, some bioethicists invoke various principles, moral theories and empirical evidence to bolster their assertions. Others [ 2 ] go as far as to claim that any attempt to establish a universal Bioethics is ultimately futile because morality is relative and therefore the correct course of action is dependent upon local culture. The current key issues championed by bioethicists include voluntary euthanasia, abortion, transplantation and doping; since it is an exemplar of the application of philosophy to medicine and is the subject of current and intense public debate [ 3 ], this essay will explore euthanasia in particular.

Health and Disease: Modern medicine operates at the unique interface between individual humans and cutting edge science, simultaneously necessitating both a patient centred and an evidence based approach. It has been claimed [ 4 ] that the questions of philosophy in medicine are derivative of those of philosophy in other areas, but this ignores the essential psychosocial dimension of medical practice. Medicine is not purely the administration of scientific knowledge upon a physical object – the patient’s body - but the co-ordinated weaving of personal and scientific approaches in which the patient and physician are “co-participants in defining the goal and achieving that goal – cure of illness or promotion of health” [ 5 ]. But what is meant by ‘health’ is not always easily discernible. Definitions of ‘health’, ‘disease’ and the demarcation between them shape research agendas and clinical practice. Therefore, a careful examination of these central concepts is essential to any thorough investigation into the nature of medicine.

Psychiatry: Over any other medical speciality, psychiatry poses unique problems to an integrated understanding of medicine. The widely referenced Diagnostic and Statistical Manual of Mental Disorders [ 6 ] treats mental disorders as clusters of symptoms, yet psychiatric patients are understood to be suffering from mental illness in the same way that an orthopaedic patient suffers from physical illness - the former a disease of the brain, the latter a disease of the bones. This “medical model” [ 7 ] seems bolstered by the emergence of dramatically effective biological therapies such as electric convulsive therapy, lithium and tricyclic antidepressants, yet the implementation of talking therapies seems to suppose that mental entities such as beliefs, emotions and perceptions have an independent causal impact. The apparent indispensability of phenomenology Footnote 2 within the diagnosis and treatment of psychiatric illness, and Medicine’s steadfast adherence to a biological model of disease whereby symptoms are necessarily caused by bodily states, poses a deep philosophical conundrum.

Central to the euthanasia debate, and indeed much of bioethics, are the 4 ethical principles: beneficence, non-maleficence, justice and autonomy. Since unpacking the meta-ethical underpinnings for these values would be arduous, they are commonly taken to be prima facie principles [ 8 ]. It is reasonable to suggest that prohibiting active euthanasia impinges on a patient’s autonomy, denying them the means to end their own life, but this compromise is justified by the principle of non-maleficence whereby killing a patient would constitute harming them under any circumstances. In addition, The Hippocratic Oath prohibits giving “a deadly drug to anybody” a deviation from which could be claimed to compromise trust in physicians and damage the moral centre of medicine [ 9 ]. The GMC states that “life prolonging treatment can lawfully be omitted or withdrawn from a patient” [ 10 ] but actively assisting a suicide is illegal in the UK at present. The contemporary euthanasia debate centres on the distinction between acts and omissions - between allowing someone to die by not acting and someone dying via a physician’s direct act.

Supporters of euthanasia commonly argue [ 11 ] that there is no clear moral distinction between acts and omissions. Allowing a child to drown in shallow water by an adult in full knowledge that they are dying could be considered to be as morally reprehensible as the adult who pushes the child into water themselves. Both the act and the omission results in the child’s avoidable death and the adult can be said to be equally blameworthy in both scenarios. Thus, the distinction between acts and omissions is illusory and one of the following options results:

Both active and passive euthanasia should be permitted on the basis that in certain dire and consensual circumstances a patient’s death would be a good thing.

Both active and passive euthanasia should be prohibited on the basis that they are equally tantamount to killing the patient.

Dissolving the distinction between acts and omissions places active and passive euthanasia on equal footings as they both involve intentionally ending a patient’s life. Since modern Medicine makes it possible (but not always desirable) to keep human beings biologically alive for a long time, one’s conviction in the physician’s legitimacy to withdraw treatment under adverse circumstances in a patient’s best interests commits one to also permit active euthanasia. This argument highlights that if active euthanasia is wrong, it cannot be simply on the basis that it is an act rather than an omission. Additional grounds for the moral distinction between active and passive euthanasia are discussed below.

Another basis for the illegality of active euthanasia might be that additional negative consequences could result. Firstly, it must be considered that permitting active euthanasia might weaken society’s commitments to provide optimal care for dying patients; as euthanasia would undoubtedly offer a cheaper alternative to invasive medical intervention, society might become less committed to providing expensive technological and pharmacological support to dying patients, and even more so at times of pressure on funding. However, this objection is based on a claim with little evidential support, and suggesting that offering active euthanasia will erode the quality of care of dying patients equates to suggesting that recognising a patient’s right to forego life-sustaining treatment will have the same effect. However, there is no persuasive evidence to that end despite withdrawal of treatment being regularly implemented. Therefore, this debate is essentially an empirical disagreement about the impact of legalising active euthanasia, but without a clear specification of how a policy would be enacted and how the potential for abuse would be diminished, these imagined consequences are largely speculative.

Secondly, it could be claimed that permitting voluntary active euthanasia may inadvertently open the door to instances of involuntary active euthanasia. It is not always easy to accurately assess whether an individual’s choice is unequivocally voluntary, such as in cases of coercion, and this element of doubt may be sufficient to prohibit active euthanasia altogether. In addition to inadvertent cases of involuntary euthanasia, there could be reason to expect that the legalisation of active euthanasia would result in pressure to legalise it in incompetent patients who are unable to express their own wishes, in much the same way that life-sustaining treatment is regularly withdrawn in the best interests of patients lacking capacity. This objection points to the fact that the consequential legalisation of the non-voluntary form of active euthanasia could greatly increase the numbers of patients on whom it might be performed, amplifying the potential for misapplication and abuse yet further.

Finally, issue is taken with the legalisation of euthanasia on the grounds of legal intrusion. The present situation whereby collaborating physicians form decisions to forego life-sustaining treatment does not require regular intervention by the judicial system. Due to the emotive nature of the issue, the introduction of lethal injections or overdoses may blur the line between medical and legal decisions, particularly in light of the issues with establishing the freedom of patient decision-making already discussed. This could also potentially undermine the hard battles medical experts have fought in order to retain autonomy from the judicial system when making decisions to withdraw treatment. While it is plausible that procedures could be designed to clearly establish the voluntariness of the patient’s request without invoking legal support, it would be naïve to suppose that this would be acceptable to the majority of society in the first instance.

Thus the case for the legalisation of euthanasia is strong on philosophical grounds but the practical concerns raised by the introduction of active euthanasia into a hitherto unfamiliar medical system presents an obstacle. It is the responsibility of advocates of active euthanasia to demonstrate clearly workable public policy which would effectively regulate and respectfully scrutinise the practice.

Health and disease

It is uncontroversial to claim that many of the activities of Medicine aim to improve health. However, the concepts of ‘health’ and ‘disease’ are not clearly defined; questions about the normality of ageing and the exact cut-off for hypertension pierce the comfortable complacency surrounding these notions. In addition, the precise meaning of ‘health’ may change according to gender, age and culture. The World Health Organisation (WHO) makes the broad statement that ‘health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ [ 12 ]. This is a useful and inclusive definition but it does not guide us when determining whether a certain condition is to be classified as ‘a disease’. Reznek [ 13 ] highlights the significance of such classifications in virtue of the impact it has on society and politics:

“The classification of a condition as a disease carries many important consequences. We inform medical scientists that they should try to discover a cure for the condition. We inform benefactors that they should support such research. We direct medical care towards the condition, making it appropriate to treat the condition by medical means such as drug therapy, surgery, and so on. We inform our courts that it is inappropriate to hold people responsible for the manifestations of the condition. We set up early warning detection services aimed at detecting the condition in its early stages when it is still amenable to successful treatment. We serve notice to health insurance companies and national health services that they are liable to pay for the treatment of such a condition. Classifying a condition as a disease is no idle matter [ 13 ].”

There are two main ideologies in the debate surrounding disease classification: normative and naturalistic. A normative conception of disease categorises certain conditions in virtue of their undesirability for the patient. However, categorising a condition as a disease should a patient consider the condition bad for them leads us to consider ugliness, shortness and hunger, for example, as pathological. In addition, some conditions which we would intuitively call diseases may confer some survival benefit upon us, such as when infestation with certain parasitic worms dampens unwanted immune responses [ 14 ] or cowpox confers immunity to smallpox. A more complex normative approach identifies disease with anything internal which involuntarily causes at least one of the three ‘3 Ds’ – disability, discomfort or deformity [ 15 ]. However, this falls foul of the objection that each one of these ‘D’ concepts is subjective and therefore a definition inclusive of these concepts will itself be subjective by extension.

A naturalistic view categorises disease according to a natural conception of biological dysfunction. This approach benefits from being potentially applicable to multiple organisms and from being more amenable to defining objectively. Borse [ 16 ] identifies a disease with physiological dysfunction of an organ or process, whereby ‘dysfunction’ is defined as subnormal function “under some arbitrarily chosen minimum level below the mean.” This statistical definition of disease, while leaving open to debate the exact cut-off point for sufficiently deviant physiology, dodges the objection from subjectivity which impeded the normative account. However, it is open to an objection derived from common sense: if every dysfunction sufficiently different from the physiological norm is deemed to be a disease then we would label organ donors and those with unusual immune receptors as ‘diseased’. Thus, it is apparent that elements of the normative and the naturalistic definitions of disease are necessary for a holistic understanding of the concept in order to prevent misapplications of the term ‘disease’. Therefore, a full understanding of the concept ‘disease’ includes both physiological dysfunction and deprivation of the individual in the present or the future.

Psychiatry poses a challenge to the Philosophy of Medicine due to the distinctive character of mental illness. Much like physical illness, mental disorders cause pain and distress in a myriad of different guises. As in non-psychiatric Medicine, psychiatric doctors are trained to apply the principles of diagnostic rigour, evidenced based therapies and effective communication skills to provide their patients with optimum care. However, there is less scientific clarity regarding the nature of mental illness than there is regarding most physical diseases, and Psychiatry’s digressions from medical practice as a whole places it in a unique position within the field. This section seeks to clarify elements of the conceptual framework which justifies Psychiatry’s inclusion as a medical specialty and argues in favour of a phenomenological understanding of mental illness.

As discussed in the previous section, in order to delineate a condition as sufficiently divergent from normal functioning to be labelled ‘a disease’ we must have a clear conception of ‘health’. This is challenging in the case of the mind because the psychological norms of different cultures and subcultures vary much more markedly than those of physiological norms. It is tempting to try to define ‘mental abnormality’ as simply ‘psychology that is undesirable to the patient’ but mental illness may not always be apparent to the sufferer; social norms play an integral role in determining whether certain behaviours are manifestations of mental illness and so one’s embeddedness within society is an important factor. In addition, the victims of psychiatric problems are sometimes subject to treatment under Section, against their will, which is seldom the case in non-psychiatric medicine; this is another feature which suggests that an understanding of mental illness from a purely a physiological perspective is too narrow a conception.

Exponents of the medical model consider psychiatry to be an applied branch of the cognitive neurosciences and mental illness a pathological process in the brain which causes the clinically observable symptoms that are elicited by psychiatrists. This position identifies the mind with the brain, conceptualising human beings as purely physical machines of which ‘the mind’ is one component. Whether the mind consists in information processing systems or molecular manifestations of gene expression, a physicalist approach places the mind squarely within the brain of the patient. This approach receives favour as it sits comfortably within our current scientific model, allowing us to use characteristic symptoms of mental illness as a temporary placeholder for the underlying physical nature of the disease and many successes have resulted from it; Alzheimer’s disease for example; a previously poorly understood condition, has now been identified with markers such as cerebral atrophy, amyloid plaques and neurofibrillary tangles [ 17 ] deduced from post-mortem evidence. Likewise, the medical model holds that the patho-physiology of conditions such as depression and schizophrenia is similarly available for investigation within the brains of patients, and that a complete and perfectly detailed understanding of the brain processes involved will be wholly explanatory of the condition.

This perspective seems to bypass the essential fact that, unlike with, say, heart disease, there is an indispensable experiential element to mental illness bound up in its definition; we may not sensibly claim that someone is suffering from depression, for example, if they do not experience irrational low mood or suicidal ideation. In addition, simple low mood or suicidal ideation themselves are not sufficient to diagnose someone with depression as there are situations where there may be rational cause for someone to feel low or to consider suicide. Upon unpacking the concept of depression, we can see it presupposes an understanding of the concept of rationality, but unlike the norms of physiology, the norms of rationality are not amenable to scientific investigation. The rationality of a certain thought is determined not by empirical evidence but by culturally established rational principles and thorough inquiry of the patient. Thus behaviour and experience is understood to be functioning well when it is directed towards the achievement of certain understandable human goals, and while it seems platitudinous to say that a brain is required to do that, it seems that there are additional essential yet subjective elements to achieving an understanding of abnormal behaviour and experience.

Thus we can see, mental disorders are in some ways like physical disease and can be understood as deviations from human norms. In the case of mental disorders, to deviate from a norm is to think, feel, intend, act, and so on, in ways which are not found to be readily intelligible by those considered to be normal. This impacts upon one’s ability to interact within one’s community and in this sense, a mental disorder is one which affects the whole of one’s being. While the intellectual traditions, basic concepts and clinical as well as research strategies of Medicine can readily be applied to Psychiatry, there are extra features inherent to the treatment of mental health which cannot be subsumed under a purely physicalistic model.

Through a detailed discussion of three salient issues in the philosophy of medicine, it has been argued that the application of profound philosophical thought to medicine and its practices reveals a depth that necessitates exploration before simply following the aims of curing all. Philosophical rigour matched with modern medicine has the potential to engage patients and help them make independent, informed decisions and assist physicians to think more clearly, analytically and empathetically.

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Fenton, R. What is the place for philosophy within the field of medicine? A review of contemporary issues in medical ethics. Philos Ethics Humanit Med 13 , 16 (2018). https://doi.org/10.1186/s13010-018-0070-3

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DOI : https://doi.org/10.1186/s13010-018-0070-3

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The Central Role of Ethics in Medical Affairs Practice

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• Volume 37 , pages 275–279, ( 2023 )

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The author argues that notwithstanding available guidelines and established practices, the elaboration of a formal ethics framework specific to medical affairs could improve good practice internationally. He further argues that further and better insights into the theory behind the practice of medical affairs are an essential precondition for elaborating any such framework.

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The notion ‘competent authority’ as it is now established in regulatory language applies to an authority that has the statutory legitimacy to act. The notion of competence sought here relates to understanding how goodness inheres in the medical affairs brief and having the wherewithal to make suitable and defensible decisions over such issues as the nature of this goodness and its applicability. The first notion of competence does not necessary imply the second.

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Acknowledgements

I am grateful to Dr. Pol Vandenbroucke MD MSc MBA FFPM, visiting senior lecturer at KCL for his comments and encouragements on an earlier draft of this work. He gives consent to be thanked here.

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Naraynassamy, C. The Central Role of Ethics in Medical Affairs Practice. Pharm Med 37 , 275–279 (2023). https://doi.org/10.1007/s40290-023-00477-9

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You need to understand medical ethics and be ready to answer ethics questions or tackle MMI stations that focus on this topic. This guide outlines the four pillars of medical ethics and introduces three ethical frameworks that you should know about.

Ethics in Medicine

Medical ethics describes the moral principles by which a Doctor must conduct themselves. You need to understand the concept of medical ethics when you’re applying for Medical School, but you aren’t expected to be an expert.

It’s worth being aware that medical ethics is a changing ideal. Something that might have been considered ethical 30 years ago may not be today – and what we think is ethical right now may change in the future.

Why Is Medical Ethics Important?

Medical professionals frequently find themselves facing moral questions and ethical dilemmas in their line of work. Medical ethics provide a framework to help them make judgement calls which are morally sound and right for the patient in question.

It’s essential for aspiring Doctors to have a good moral compass and a solid grasp of medical ethics so they can consistently do what is best for their patients.

Four Pillars of Medical Ethics

The four pillars of medical ethics are:

• Beneficence (doing good)
• Non-maleficence (to do no harm)
• Autonomy (giving the patient the freedom to choose freely, where they are able)
• Justice (ensuring fairness)

These four principles represent a framework for analysing the best action to take in a given situation. To use this approach, you must consider whether your actions are in compliance with each of the four pillars.

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Example Ethical Dilemma

A good example of an ethical dilemma relating to Medicine is that of surgery.

Imagine that a patient has appendicitis and the surgeons believe that surgery is necessary. Technically, making an incision into the patient’s skin is causing “harm” to the patient; however, this is done with good intent as removing the inflamed appendix eliminates the risk of progression to rupture and peritonitis.

Surgery would be offered to the patient based on their clinical need and they will have the right to make an informed decision. The four principles would, therefore, support performing this surgery.

Medical Ethics Concept: Consequentialism

Consequentialism is an ethical ideology that states the morality of an action is dependent purely on its consequences. A simpler way to phrase this would be that the “ends justify the means”. If your action has an overall benefit, then it does not matter about the action itself.

Example: Your patient has a terminal illness and is not likely to survive the operation she is about to undertake. Just as she is about to be anaesthetised, she asks you: “Doctor, will I be okay?” A consequentialist ideology supports that lying in this circumstance is acceptable, even though lying itself is not a moral action.

Medical Ethics Concept: Utilitarianism

Utilitarianism says the best action is that one that brings about the best increase in utility (benefit). Utility is generally considered on a broad scale, often taking into consideration wider society and not just the patient in question. It’s a form of consequentialism.

Example: You have a sum of money to either fund a very expensive treatment for one patient with a rare disease or five patients with a very common and easy-to-treat disease. Utilitarian ethics dictates that treating the five patients is morally superior as a greater overall benefit is achieved.

Medical Ethics Concept: Deontology

Deontology is also known as “duty-based ethics”. This ideology states that the correct course of action is dependent on what your duties and obligations are. It means that the morality of an action is based on whether you followed the rules, rather than what the consequence of following them was.

This is in direct contrast with consequentialism.

Example: If your terminally ill patient asks if they’ll be ok after a surgery they’re unlikely to survive, a deontological approach would suggest you don’t lie to comfort them. That’s because according to this concept, lying isn’t morally acceptable because it’s our obligation not to lie – no matter the consequences.

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Generally speaking, consequentialism may be the most relevant guide to thinking about the broad aims of healthcare – and deontology-based guidance is the one most commonly seen in Medicine.

How To Develop Medical Ethics Knowledge

One of the best ways to develop your understanding of medical ethics is to practice analysing situations using ethical frameworks and ideologies. You can do this on your own, with a teacher, or with a fellow Medical School applicant who could give you their perspective and share ideas. Try to compare the outcomes given by different frameworks and consider the implications of this.

Make sure you stay up-to-date with the latest health news – and see how these ethical frameworks apply to what’s currently in the news.

Medical Ethics Examples

At Medical School interviews, medical ethics is a big part of the selection process. It’s highly likely that you’ll be asked ethics questions or face an MMI station designed to test your understanding of these concepts.

Some key medical ethics examples that you should be aware of for your interview are:

• The Charlie Gard and Alfie Evans cases
• Medicinal cannabis
• The handling of the COVID-19 pandemic
• Organ donation

When you answer ethics questions, you don’t have to list each of the four principles of ethics and outline these concepts – instead, pick a couple that are really relevant to show the interviewer that you’re aware of medical ethics in general.

And remember – you may not be expected to make decisions yet. The key thing to do in your interview is to show you understand the issues by discussing how the key ethical principles relate to the question. If the interviewer pushes you for an opinion, make sure you can back up what you choose with some ethical reasoning.

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Essay on Medical Ethics

Students are often asked to write an essay on Medical Ethics in their schools and colleges. And if you’re also looking for the same, we have created 100-word, 250-word, and 500-word essays on the topic.

Let’s take a look…

100 Words Essay on Medical Ethics

What is medical ethics.

Medical ethics is a set of rules that doctors and healthcare workers follow to give the best care to patients. It’s like a guide for making sure everyone is treated fairly and kindly in medical situations.

Respecting Patients

One big part of medical ethics is respecting patients. This means doctors must listen to patients, keep their information private, and let them make choices about their own health.

Doing No Harm

Doctors promise to not hurt patients. They must be careful and avoid causing any harm while trying to help. This is a very old rule in medicine, known as “do no harm.”

Medical ethics also means being fair. Doctors should treat everyone the same, no matter who they are. They must give the same high-quality care to all patients.

Staying Honest

Honesty is key in medical ethics. Doctors should always tell the truth about treatments and health. This helps patients trust them and make good decisions about their care.

250 Words Essay on Medical Ethics

Medical ethics is about right and wrong in medicine. It guides doctors, nurses, and other health workers to make good choices for their patients. Imagine being sick and needing someone to trust with your health. That’s where medical ethics comes in. It helps make sure everyone is treated fairly and with respect.

Rules for Doctors

Doctors follow special rules called the Hippocratic Oath. This promise makes them agree to help patients, not harm them, and keep their information private. It’s like a secret promise to take good care of people who are sick.

Keeping Secrets

One big rule in medical ethics is privacy. This means doctors should keep what they know about your health just between you and them. It’s important because it helps you feel safe to tell your doctor everything they need to know to help you.

Choosing Fairly

Sometimes, doctors have to make tough choices, like who gets a new medicine first when there’s not enough for everyone. Medical ethics helps them decide in a way that’s fair and doesn’t pick favorites.

Respecting Choices

Patients have the right to make choices about their own health. Doctors should listen and respect what you want, even if it’s different from what they think is best. It’s like being the boss of your own body.

In conclusion, medical ethics is about making good, fair, and respectful choices in healthcare. It’s a set of rules that help doctors and patients work together to make the best decisions.

500 Words Essay on Medical Ethics

What are medical ethics.

Medical ethics are rules that help doctors and health workers make good choices when they care for patients. These rules are important because they guide professionals to do what is right and fair for everyone. Imagine you’re playing a game. Rules in a game help you understand what you can and cannot do. Similarly, medical ethics are like rules for doctors and nurses, telling them how to do their job well and treat patients kindly.

Respect for Patients

One big rule in medical ethics is to respect patients. This means doctors should listen to what patients want for their health. For example, if a patient doesn’t want to take a certain medicine, the doctor should respect their choice. It is also about keeping secrets. When you tell a doctor something private, they should not tell anyone else. This is called patient confidentiality.

Doing Good and Not Harming

Doctors should always try to help and not hurt their patients. This idea is often said in Latin as “Primum non nocere,” which means “First, do no harm.” It’s like when you’re playing with friends; you want to have fun but not hurt anyone. Doctors must make sure that the treatments they give do not cause more problems than they solve.

Fairness is also a key part of medical ethics. This means that doctors should treat everyone equally. It doesn’t matter who the patient is, where they come from, or how much money they have. Everyone should get the same chance to receive good health care. Think of it like sharing toys; everyone should get a turn.

Telling the Truth

Telling the truth, also known as honesty, is very important in medical ethics. Doctors should always give clear and truthful information to their patients. If a treatment has risks, they should explain those risks. It’s like when a friend asks you if their drawing is good; you should be kind but also tell the truth if there is something they can improve.

Keeping Promises

Doctors should keep their promises. If they say they will do something, like call you with test results, they should do it. This builds trust between doctors and patients. It’s like when you promise to give back a borrowed pencil; your friend trusts you to do what you said.

Improving Themselves and the Profession

Finally, doctors should always try to get better at what they do. They should learn new things and improve their skills. This helps them take better care of their patients. It’s similar to practicing a sport or a musical instrument; the more you practice, the better you get.

In conclusion, medical ethics are a set of rules that help doctors and health workers make the best decisions for their patients. They include respecting patients, doing good, being fair, telling the truth, keeping promises, and always trying to improve. These rules make sure that when you go to a doctor, you are treated with care, honesty, and respect.

That’s it! I hope the essay helped you.

If you’re looking for more, here are essays on other interesting topics:

• Essay on Dealing With Personal Challenges
• Essay on Media Violence
• Essay on Media Trust

Apart from these, you can look at all the essays by clicking here .

Happy studying!

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Medical Ethics Issues: Position Papers & Resources

In addition to the ACP Ethics Manual, ACP publishes ethics position papers on a broad range of health care ethics issues including clinical ethics, professionalism, the delivery of health care, teaching, medical research, human rights and other topics. ACP ethics policy is approved by the Board of Regents and serves as the basis for the development of ACP ethics education and practice resources and legislative, regulatory and policy implementation activities.

Current ACP Ethics Policies and Resources

New determination of death and organ transplantation, position papers.

• Standards and Ethics Issues in the Determination of Death: A Position Paper From the American College of Physicians (September 4, 2023)
• Ethics, Determination of Death, and Organ Transplantation in Normothermic Regional Perfusion (NRP) with Controlled Donation after Circulatory Determination of Death (cDCD): American College of Physicians Statement of Concern (April 17, 2021)

Comments and Letters

• ACP letter to the Uniform Law Commission Committee about updating the Uniform Determination of Death Act (UDDA) (June 7, 2023)
• Does Normothermic Regional Perfusion Violate the Ethical Principles Underlying Organ Procurement? Yes. (Chest. 2022;162(2):288-90)
• Rebuttal From Dr. DeCamp et al. (Chest. 2022;162(2):292-3)

NEW Disability

• ACP Letter Regarding Discrimination on Basis of Disability in Health and Human Service Programs Proposed Rule 2023 (November 13, 2023)

NEW Electronic and Online Professionalism

Ethics manual, electronic patient-physician communication, electronic health records, telemedicine, and online professionalism.

• Initiating and Discontinuing the Patient–Physician Relationship
• The Medical Record
• Boundaries and Privacy

Case Studies

• Lab Results Reporting, Ethics, and the 21st Century Cures Act Rule on Information Blocking CME/MOC

Ethics, Electronic Health Record Integrity and the Patient-Physician Relationship CME/MOC (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2021)

Ethics, Professionalism, and the Physician Social Media Influencer CME/MOC (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2020)

”Doctor, Can’t You Just Phone a Prescription In?” and Other Ethical Challenges of Telemedicine Encounters CME/MOC (ACP Ethics Case Studies Series. MOC and CME by Medscape. 2019)

Maintaining Medical Professionalism Online: Posting of Patient Information CME (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Addressing a Colleague's Sexually Explicit Facebook Post CME (ACP Ethics Case Studies Series. CME by Medscape. 2017)

Copied and Pasted and Misdiagnosed (or Cloned Notes and Blind Alleys) CME (ACP Ethics Case Studies Series. CME by Medscape. 2015)

American College of Physicians Ethical Guidance for Electronic Patient-Physician Communication: Aligning Expectations (J Gen Intern Med. published online 22 June 2020)

Ethical Implications of the Electronic Health Record: In the Service of the Patient (J Gen Intern Med. 2017;32:935-9)

Policy Recommendations to Guide the Use of Telemedicine in Primary Care Settings (Ann Intern Med. 2015;163:787-9)

Online Medical Professionalism: Patient and Public Relationships (Ann Intern Med. 2013;158:620-7)

NEW End-of-Life Care

• Care of Patients Near the End of Life
• Show Codes, Slow Codes, Full Codes, or No Codes: What Is a Doctor to Do? CME/MOC (ACP Ethic Case Studies Series, MOC and CME by Medsape. 2023)

2011 Letter and 2009 letter to Congressman Blumenauer regarding ACP’s support for legislation to pay for voluntary end-of-life care consultations (see H.R. 1898, the Life Sustaining Treatment Preferences Act of 2009).

• Ethics, Determination of Death, and Organ Transplantation in Normothermic Regional Perfusion (NRP) with Controlled Donation after Circulatory Determination of Death (cDCD): American College of Physicians Statement of Concern

End-of-Life (PEACE) Brochures (ACP. 2014) The PEACE brochures were developed by the Patient Education Work Group, which was convened in conjunction with the Consensus Panel project. Order copies of printed brochures

• Improving Your End-of-Life Care Practice
• Living with a Serious Illness: Talking with Your Doctor When the Future is Uncertain
• When You Have Pain at the End of Life
• Making Medical Decisions for a Loved One at the End of Life

ACP-ASIM End-of-Life Care Consensus Panel Papers (1999-2001) ACP convened this Greenwall Foundation supported consensus panel to develop ethical, policy, and clinical recommendations for physicians and other clinicians on end-of-life decisions.

Physician's Guide to End-of-Life Care Edited by Lois Snyder, JD, and Timothy Quill, MD, FACP (ACP Books. 2001)

Advance Directive Forms for Your State Contact Caring Connections, a program of the National Hospice and Palliative Care Organization (NHPCO).

National Healthcare Decisions Day, April 16 Details and resources on NHDD and the importance of advance care planning.

• Expert Witnesses

To Be or Not to Be: Should I Serve as an Expert Witness? CME (ACP Ethics Case Studies Series. CME by Medscape. 2014)

Guidelines for the Physician Expert Witness (Ann Intern Med. 1990;113:789)

NEW Family Caregivers

Ethical Guidance on Family Caregiving, Support, and Visitation in Hospitals and Residential Health Care Facilities, Including During Public Health Emergencies (J Gen Intern Med. 2023 Mar 20:1–8)

Family Caregivers, Patients and Physicians: Ethical Guidance to Optimize Relationships (J Gen Intern Med. 2010;25:255-60)

Family Caregivers, Patients and Physicians: Ethical Guidance to Optimize Relationships (ACP. 2009) (This publication is a longer version of the position paper above.)

Information Resources for Physicians Supporting Family Caregivers (ACP. 2010) This appendix of resources was developed in conjunction with the ACP position paper to help physicians manage relationships with patients and caregivers.

When the Family Caregiver Is a Physician: Negotiating the Ethical Boundaries CME/MOC (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2020)

Genetic Testing and Precision Medicine

• Precision Medicine, Genetic Testing, Privacy, and Confidentiality

ACP Comments on privacy protection and human genome sequencing (May 24, 2012) ACP provided comments to the Presidential Commission for the Study of Bioethical Issues regarding the ethical implications of evolving notions of privacy and access in relation to the integration of large-scale human genome sequencing into research and clinical care.

Position Papers and Statements

Ethical Considerations in Precision Medicine and Genetic Testing in Internal Medicine Practice Ann Intern Med.2022;175:1322-1323

Genetic Testing and Reuniting Families (July 10, 2018)

Global Health Clinical Experiences

• Cultural Humility and Volunteerism

Ethical Obligations Regarding Short-Term Global Health Clinical Experiences (Ann Intern Med. 2018;168:651-7)

NEW Health and Human Rights

"Health and human rights are interrelated. When human rights are promoted, health is promoted ... Physicians have important roles in promoting health and human rights and addressing social inequities." (Ethics Manual, seventh edition).

• Obligations of the Physician to Society

Health as a Human Right (Ann Intern Med. doi:10.7326/M23-1900)

ACP's Human Rights Page : ACP policy statements and letters of support, as well as documents related to College advocacy for the humane treatment of prisoners and detainees.

NEW Health Information Privacy, Protection, and Use

• Confidentiality
• Research Sections within the Research chapter include “Use of Human Biological Materials in Research” and “Internet and Social Media Research”.

Maintaining Medical Professionalism Online: Posting of Patient Information (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Confidentiality and Privacy: Beyond HIPAA to Honey, Can We Talk? (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Ethical Guidance for Physicians and Health Care Institutions on Grateful Patient Fundraising: A Position Paper From the American College of Physicians (Ann Intern Med.doi:10.7326/M23-1691)

Health Information Privacy, Protection, and Use in the Expanding Digital Health Ecosystem: A Position Paper of the American College of Physicians (Ann Intern Med.2021;174:994-998)

NEW Pandemics and Ethics -->

Health care system catastrophes.

• The Patient-Physician Relationship and Health Care System Catastrophes
• Medical Risk to Physician and Patient

When Resources Are Limited During a Public Health Catastrophe: Nondiscrimination and Ethical Allocation Guidance CME/MOC (ACP Ethics Case Studies Series. MOC and CME by Medscape. 2023)

Pandemic Treatment Resource Allocation Ethics and Nondiscrimination (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2020)

Stewardship of Health Care Resources: Allocating Mechanical Ventilators During Pandemic Influenza (ACP Ethics Case Studies Series. 2017)

ACP supports ACIP recommendation for additional mRNA COVID-19 vaccine dose and WHO call for equitable global vaccine distribution (August 17, 2021)

ACP Statement on Global COVID-19 Vaccine Distribution and Allocation: On Being Ethical and Practical (June 8, 2021)

ACP's Policy Statement on the Ethical Allocation of Vaccines During Pandemics Including COVID-19 (November 23, 2020)

A Wake-up Call for Healthcare Emerging Ethical Lessons from Covid-19 (Modern Healthcare, June 16, 2020)

Non-Discrimination in the Stewardship of Healthcare Resources in Health System Catastrophes, including COVID-19 Pandemic (March 26, 2020)

Internists Say Harassment Based on Race or Ethnic Origin is Never Okay (March 31, 2020)

Universal Do-Not-Resuscitate Orders, Social Worth, and Life-Years: Opposing Discriminatory Approaches to the Allocation of Resources During the COVID-19 Pandemic and Other Health System Catastrophes (Ann Intern Med.2020;173:230-232)

NEW Patient–Physician Relationship

Patient-physician relationship.

• The Physician and the Patient
• Initiating and Discontinuing the Patient-Physician Relationship
• Third-Party Evaluations
• Providing Medical Care to One’s Self; Persons With Whom the Physician has a Preexisting Close Nonprofessional Relationship or a Reporting Relationship; and VIPs
• Sexual Contact between Physician and Patient
• Gifts from Patients

Confidentiality and privacy, disclosure of medical errors, and informed and surrogate decision making

• Informed Decision Making and Consent
• Making Decisions Near the End of Life

The Doctor Will See You Shortly. The Ethical Significance of Time for the Patient–Physician Relationship (J Gen Intern Med. 2005;20:1057-62)

Ethics and Time, Time Perception, and the Patient–Physician Relationship (ACP. March 2003) (This publication is a longer version of the position paper above.)

• Patient Prejudice? The Patient Said What?... and What Comes Next CME (ACP Ethics Case Studies Series. CME by Medscape. 2022)

Confidentiality and Privacy: Beyond HIPAA to Honey, Can We Talk? CME (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Preventive Health Screening, Ethics, and the Cognitively Impaired Patient CME (ACP Ethics Case Studies Series. CME by Medscape. 2015)

The Difficult Patient: Should You End the Relationship? What Now? An Ethics Case Study CME (ACP Ethics Case Studies Series. CME by Medscape. 2014)

Must You Disclose Mistakes Made by Other Physicians? CME (ACP Observer. November 2003)

Physicians and Society

• Relation of the Physician to Government
• Strikes and Other Joint Actions by Physicians

Physician Work Stoppages and Political Demonstrations—Economic Self-Interest or Patient Advocacy? Where Is the Line? CME (ACP Ethics Case Studies Series. CME by Medscape. 2010)

• Physician-Assisted Suicide and Euthanasia
• Toolkit on Issues in Delivering Patient-Centered End-of-Life Care and Responding to a Request for Physician-Assisted Suicide (Member login)

Ethics and the Legalization of Physician-Assisted Suicide (Ann Intern Med. 2017;167:576-8)

Physician–Industry Relations

• Conflicts of Interest
• Sponsored Research

Physician Open Payments (Sunshine Rule) This ACP webpage provides guidance and related tools for physicians on the Physician Payment Sunshine Rule (also referred to as the National Physician Payment Transparency Program, or Open Payments). The Open Payments system, implemented by the Centers for Medicare and Medicaid Services (CMS) in 2015, provides a mechanism for the public reporting of physician and teaching hospital financial relationships with industry.

Physician–Industry Relations. Part 1: Individual Physicians (Ann Intern Med. 2002;136:396-402)

Physician–Industry Relations. Part 2: Organizational Issues (Ann Intern Med. 2002;136:403-6)

NEW Practice Models, the Business of Medicine and the Changing Practice Environment

• The Changing Practice Environment
• Financial Arrangements

Ethics, Professionalism, Physician Employment and Health Care Business Practices CME/MOC

Banning Harmful Health Behaviors as a Condition of Employment: Where There's Smoke There's Fired? CME (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Wellness Programs and Patient Goals of Care CME (ACP Ethics Case Studies Series. CME by Medscape. 2017)

Obligations and Opportunities: The Role of Clinical Societies in the Ethics of Managed Care (J Am Geriatr Soc. 1998;46:378-80)

Ethical and Professionalism Implications of Physician Employment and Health Care Business Practices CME (Ann Intern Med. published online 15 March 2021)

Assessing the Patient Care Implications of “Concierge” and Other Direct Patient Contracting Practices (Ann Intern Med. 2015;163:949-52)

The Patient-Centered Medical Home: An Ethical Analysis of Principles and Practice (J Gen Intern Med. 2013;28:141-6)

Ethical Considerations for the Use of Patient Incentives to Promote Personal Responsibility for Health: West Virginia Medicaid and Beyond (ACP. 2010)

Pay-for-Performance Principles That Promote Patient-Centered Care: An Ethics Manifesto (Ann Intern Med. 2007;147:792-4)

Pay-for-Performance Principles that Ensure the Promotion of Patient Centered Care—An Ethics Manifesto (ACP. 2007) (This publication is a longer version of the position paper above.)

Medical Professionalism in the Changing Health Care Environment: Revitalizing Internal Medicine by Focusing on the Patient–Physician Relationship (ACP. 2005)

Ethics in Practice: Managed Care and the Changing Health Care Environment (Ann Intern Med. 2004;141:131-6)

Selling Products Out of the Office (Ann Intern Med. 1999;131:863-4)

Prescription Drug Abuse

Prescription Drug Abuse (Ann Intern Med. 2014;160:198-200)

NEW Professionalism

American College of Physicians Pledge (ACP. 1982 [updated; original 1924]) The ACP Pledge is taken by new Fellows at Convocation at each Internal Medicine annual meeting. The Pledge affirms the physician’s membership in an ethical and moral community dedicated to healing, comfort, and altruism.

Physician Charter on Professionalism

Medical Professionalism in the New Millennium: A Physician Charter (Ann Intern Med. 2002;136:243-6)

• Professionalism

Ethical and Professionalism Implications of Physician Employment and Health Care Business Practices (Ann Intern Med. published online 15 March 2021)

• ACP Professional Accountability Principles (ACP. March 2018)

Professional Attire and the Patient-Physician Relationship CME/MOC (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2020)

Addressing a Colleague's Unprofessional Behavior During Sign-Out CME (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Dealing with the "Disruptive" Physician Colleague CME (ACP Ethics Case Studies Series. CME by Medscape. 2009)

Professional Well-being and Ethics

• The Impaired Physician

Physician Suicide Prevention: The Ethics and Role of the Physician Colleague and the Healing Community CME/MOC

When an Aging Colleague Seems Impaired CME (ACP Ethics Case Studies Series. CME by Medscape. 2017)

Physician Suicide Prevention and the Ethics and Role of a Healing Community: An American College of Physicians Policy Paper (J Gen Intern Med. 2021 Sep;36(9):2829-2835)

Physician Impairment and Rehabilitation: Reintegration Into Medical Practice While Ensuring Patient Safety (Ann Intern Med. 2019;170(12):871-879.)

ACP’s Physician Well-being and Professional Satisfaction initiative aims to foster a culture of wellness, reduce administrative burdens on physicians, improve practice efficiency and enhance individual physician well-being. The project website includes tools and programs for individual members, their practices, and ACP Chapters.

Research Ethics and Human Subjects

Research Sections within the chapter include “Protection of Human Subjects,” “Use of Human Biological Materials in Research,” “Placebo Controls,” “Innovative Medical Therapies,” “Scientific Publication,” “Sponsored Research” and “Public Announcement of Research Discoveries.”

Responsible Conduct of Research (RCR) Project

Under a grant from the Association of American Medical Colleges and the DHHS Office of Research Integrity, ACP Ethics staff has implemented member education and support programs on the responsible conduct of office-based research. Workshops have been presented at ACP's annual meeting as well as at several ACP chapter meetings.

Research in the Physician's Office: Navigating the Ethical Minefield (Hastings Cent Rep. 2008)

Volunteering for a Research Study? Talk with Your Doctor About What You Should Know This patient education brochure provides information and guidance to patients who are considering volunteering for a research study. The brochures are designed to facilitate conversations between doctors and their patients. They are intended for distribution in doctors’ offices and come in packages of 50. Access the brochure order form .

Author! Author! Who Should Be Named in a Published Study? An Ethics Case Study CME (ACP Ethics Case Studies Series. CME by Medscape. 2014)

When are Industry-Sponsored Trials a Good Match for Community Doctors? CME (ACP-ASIM Observer. 2001)

Research Ethics Training Resources

• Revised Common Rule Educational Materials , Department of Health and Human Services
• The Research Clinic , Office of Research Integrity, Department of Health and Human Services
• Responsible Conduct of Research (RCR) , Research Ethics and Compliance Training, CITI Program
• Responsible Conduct of Research Training , Office of Intramural Research, National Institutes of Health
• HIPAA Training and Resources , Department of Health and Human Services
• Online Ethics Center for Engineering and Science , Center for Engineering Ethics and Society, National Academy of Engineering
• World Association of Medical Editors (WAME)
• Council of Science Editors (CSE)
• European Association of Science Editors (EASE)

ACP supports National Academies’ call for withdrawal of Notice of Proposed Rulemaking (NPRM) for ‘Common Rule’ and for appointing a new commission (Dec. 31, 2015) ACP issued a statement in support of the National Academies' call for withdrawal of the Common Rule NPRM and for appointing a new research ethics commission.

ACP Comments on Notice of Proposed Rule Making (NPRM) (Dec. 31, 2015) ACP submitted comments to the Office for Human Research Protections of the U.S. Department of Health and Human Services on the Notice of Proposed Rule Making, "Federal Policy for the Protection of Human Subjects," also known as the Common Rule. ACP also submitted an earlier round of comments on the proposed rule making on Oct. 25, 2011.

Stewardship of Health Care Resources

"Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly in practicing high-value care. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient puts the patient first but also respects the need to use resources wisely and to help ensure that resources are equitably available" (Ethics Manual, seventh edition).

Conflicting duties? The physician's primary duty, first and foremost, is to the individual patient. She or he must advocate for the patient—in a health care system that grows more and more complex by the year—based on the best interests of the patient. But the physician also should use health care resources responsibly and efficiently. Are these duties in conflict? The Ethics Manual and ethics case studies explore these issues and provide help in sorting them out.

Is it rationing? Parsimonious care is not rationing. The goal of medical parsimony is to provide the care necessary for the patient's good on the basis primarily of evidence-based medicine. Although this may have the welcome side effect of preserving resources, reducing resource use is not the intent. It is this difference in intent and action that helps provide a foundation for the ethical distinction between parsimonious medicine and rationing.

• Resource Allocation

ACP’s High Value Care Project aims to improve health, avoid harms, and eliminate wasteful practices. The project website offers learning resources for clinicians and medical educators, clinical guidelines, best practice advice, case studies and patient resources on a wide variety of related topics.

Patient Requests for Specific Care: 'Surely You Can Explain to My Insurer That I Need Boniva?' CME (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Who Should Get What? Mammography and the Stewardship of Health Care Resources CME (ACP Ethics Case Studies Series. CME by Medscape. 2012)

The following ethics case studies were developed through an award from the ABIM Foundation's Putting the Charter into Practice project. Watch a video report of the ACP's work on this project presented by Dr. David Fleming, former President of the College.

Stewardship of Health Care Resources: Allocating Mechanical Ventilators During Pandemic Influenza CME (ACP Ethics Case Studies Series. CME by Medscape. 2017)

Stewardship of Health Care Resources: Responding to a Patient's Request for Antibiotics (ACP Ethics Case Studies Series. CME by Medscape. 2014)

Teaching, Training and the Hidden Curriculum

• Attending Physicians and Physicians-in-Training

Resident Duty Hours: To Hand Over or Gloss Over? CME (ACP Ethics Case Studies Series. CME by Medscape. 2017)

Hidden Curricula, Ethics, and Professionalism: Optimizing Clinical Learning Environments in Becoming and Being a Physician (Ann Intern Med. 2018;168:506-8)

CME/MOC activities based on this ACP position paper are available:

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Ethics, Professionalism, and the Hidden Curriculum (Click on “CME/MOC” on the left sidebar.)

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In this Curbsiders Podcast , Sanjay Desai, MD, coauthor of ACP’s position paper and Internal Medicine program director at Johns Hopkins, reviews several cases that illustrate how institutional norms can shape the practice of medicine. Detailed summaries of the cases discussed are available here .

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• Focusing attention on physicians’ climate-related duties may risk missing the bigger picture: towards a systems approach to health and climate
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• http://orcid.org/0000-0001-8111-2730 Gabby Samuel 1 , 2 ,
• Sarah Briggs 2 ,
• Faranak Hardcastle 2 , 3 ,
• Kate Lyle 2 ,
• Emily Parker 2 ,
• http://orcid.org/0000-0003-3324-4338 Anneke M Lucassen 2
• 1 Department of Global Health and Social Medicine , King's College London , London , UK
• 2 Centre for Human Genetics, Nuffield Department of Medicine , University of Oxford , Oxford , UK
• 3 Nationals Centre for Public Awareness of Science , Australian National University , Canberra , ACT , Australia
• Correspondence to Dr Gabby Samuel, Department of Global Health and Social Medicine, Bush House, North East Wing, 40 Aldwych, King's College London, London WC2B 4BG, UK; gabrielle.samuel{at}kcl.ac.uk

https://doi.org/10.1136/jme-2024-109953

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Gils-Schmidt and Salloch recognise that human and climate health are inextricably linked, and that mitigating healthcare-associated climate harms is essential for protecting human health. 1 They argue that physicians have a duty to consider how their own practices contribute to climate change, including during their interactions with patients. Acknowledging the potential for conflicts between this duty and the provision of individual patient care, they propose the application of Korsgaard’s neo-Kantian account of practical identities to help navigate such scenarios. In this commentary, we argue that by focusing attention on this physician–patient level, the authors overlook the complexity of climate change, both within the healthcare sector and beyond. We recognise the importance of individual agency in tackling this issue, and we also recognise that the authors do briefly acknowledge the importance of considering these broader complexities; however, we emphasise the need for climate and health discussions/action to be situated in a wider framework of systemic change. Our concern is that overemphasis on patient-level interactions risks normalising the prioritisation of individual-level approaches to addressing climate change, detracting from such a broader approach.

Individual approach versus systems thinking

Physician training emphasises the need for trust, confidentiality and shared decision-making in the doctor–patient relationship. Similarly, biomedical ethics often foregrounds personal autonomy, with much of the ethics literature centred on resolving tensions in clinical decision-making for specific patients. In contrast, intervening in the relationship between climate and health requires us to ask questions about health and climate change that go beyond a narrow individual focus. We require an expansive approach that brings physician agency together with a comprehensive broader understanding of the socio/geopolitical factors that operate within and beyond health system structures to affect climate and health. This approach needs to recognise that while it may be appropriate for climate protection to enter the dialogue between physicians and patients, foregrounding and prioritising a wider framing of systems-level thinking is necessary.

Case study: the green inhaler

Metered-dose inhalers have a significant carbon footprint 1 and, as such, have become an international focal point for reducing healthcare-associated greenhouse gas emissions. 4 Dry powder inhalers offer a lower-carbon alternative suitable for many patients with asthma and chronic obstructive pulmonary disease, and are the norm in some countries. 5 In the UK, metered-dose inhalers make up around 70% of those prescribed and account for 3.9% of National Health Service (NHS) greenhouse gas emissions. 6 Supporting and incentivising general practitioners to discuss the environmental impact of metered-dose inhalers with their patients and offer the option to switch to dry powder inhalers or lower-emission metered-dose inhalers forms a core component of the English NHS’s Net Zero strategy. 7 Focusing here on the doctor–patient dialogue as the locus of change draws attention away from structural mechanisms such as regulatory approaches, which, in a functioning regulatory system, would have the potential to bring about quicker and longer-lasting reform. Furthermore, concentrating on replacing one healthcare product with another as a method of reducing the carbon footprint of asthma care risks obscuring the social and environmental factors associated with poor respiratory health, which have led to an increased need for inhalers in the first place. These include, for example, both outdoor air pollution from petrol/diesel vehicles, fossil fuel burning power stations and indoor wood fires, and poor indoor air quality from damp and mould exacerbated by substandard housing and fuel poverty. Addressing these issues would not only improve population health and reduce healthcare activity, thereby driving down healthcare-associated emissions, but importantly would also go some way to reducing the unequal impact of air pollution on already disadvantaged communities. This does not mean that physicians have no role here: physicians should use their trusted voices to inform and advocate for their patients and communities on the damaging health effects of air pollution.

By drawing on individual-level frameworks to assist physician decision-making around issues of climate and health, attention is moved from the fact that such issues can, should and need to be addressed through a systems-level lens. Such a lens incorporates individual as well as structural perspectives. Systems-level thinking offers a useful framework to do this. Through such a lens, physicians can more productively address issues of climate change by advocating for their patients and communities effectively.

• van Gils-Schmidt HJ ,
• World Health Organisation
• World Health Organization
• Ortsäter G ,
• Borgström F ,
• Soulard S , et al
• Wilkinson AJK ,
• Braggins R ,
• Steinbach I , et al
• NHS England and NHS improvement

X @annekeluc

Contributors All authors contributed equally to this work.

Funding This study was funded by Wellcome (222180/Z/20/Z and 208053/B/17/Z), SB is funded by an NIHR Academic Clinical Lectureship (CL-2022-13-001).

Competing interests None declared.

Provenance and peer review Not commissioned; internally peer reviewed.

↵ A ‘carbon footprint’ is an estimate of greenhouse gas emissions associated with a particular product, process or organisation. The greenhouse gases included in a carbon footprint are carbon dioxide (CO 2 ), methane, nitrous oxide and fluorinated gases, which are converted into CO 2 equivalents according to their global warming potential. The carbon footprint of metered-dose inhalers is largely attributed to the fluorinated gases released during their use, but it also encompasses greenhouse gas emissions released during their manufacture, distribution and disposal.

Linked Articles

• Feature article Physicians’ duty to climate protection as an expression of their professional identity: a defence from Korsgaard’s neo-Kantian moral framework Henk Jasper van Gils-Schmidt Sabine Salloch Journal of Medical Ethics 2023; - Published Online First: 25 Oct 2023. doi: 10.1136/jme-2023-109203

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• How the low carbon economy can improve health Andy Haines et al., BMJ, 2012
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Reproductive ethics in clinical practice : preventing, initiating, and managing pregnancy and delivery: essays inspired by the MacLean Center for Clinical Medical Ethics Lecture Series

"Like all clinicians, reproductive health care providers face specialty-specific ethical questions. However, the first editor of this book, Dr. Julie Chor (JC), has never found an ethics text that ...

"Like all clinicians, reproductive health care providers face specialty-specific ethical questions. However, the first editor of this book, Dr. Julie Chor (JC), has never found an ethics text that is tailored to the needs of practicing clinicians, students, and trainees in Reproductive Healthcare. This is an unfortunate gap in the literature, because whether reproductive health providers come from Obstetrics and Gynecology, Family Medicine, Pediatrics or another field, they all must be able to identify and analyze complex ethical issues that lie at the crossroads of patient decision-making, scientific advancement, political controversy, government regulation, and profound moral considerations in the context of continually evolving medical, legal, and societal factors. To fill this gap, Dr. Chor invited co-editor Professor Katie Watson (KW) to partner in creating the text that she has always longed to use but has never found as an Obstetrician-Gynecologist practicing and teaching in this complex milieu"--

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• Chor, Julie, editor
• Watson, Katie, editor
• New York, NY : Oxford University Press, [2021]
• Essays inspired by the MacLean Center for Clinical Medical Ethics Lecture series
• xxi, 261 pages ; 25 cm
• Includes bibliographical references and index.
• Section 1. Contraception and abortion ethics: Preventing pregnancy and birth -- Section 2. Assisted reproduction ethics: Initiating pregnancy -- Section 3. Obstetric ethics: Managing pregnancy and delivery
• Reproductive health -- Ethics.
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Guest Essay

The Problem With Saying ‘Sex Assigned at Birth’

By Alex Byrne and Carole K. Hooven

Mr. Byrne is a philosopher and the author of “Trouble With Gender: Sex Facts, Gender Fictions.” Ms. Hooven is an evolutionary biologist and the author of “T: The Story of Testosterone, the Hormone That Dominates and Divides Us.”

As you may have noticed, “sex” is out, and “sex assigned at birth” is in. Instead of asking for a person’s sex, some medical and camp forms these days ask for “sex assigned at birth” or “assigned sex” (often in addition to gender identity). The American Medical Association and the American Psychological Association endorse this terminology; its use has also exploded in academic articles. The Cleveland Clinic’s online glossary of diseases and conditions tells us that the “inability to achieve or maintain an erection” is a symptom of sexual dysfunction, not in “males,” but in “people assigned male at birth.”

This trend began around a decade ago, part of an increasing emphasis in society on emotional comfort and insulation from offense — what some have called “ safetyism .” “Sex” is now often seen as a biased or insensitive word because it may fail to reflect how people identify themselves. One reason for the adoption of “assigned sex,” therefore, is that it supplies respectful euphemisms, softening what to some nonbinary and transgender people, among others, can feel like a harsh biological reality. Saying that someone was “assigned female at birth” is taken to be an indirect and more polite way of communicating that the person is biologically female. The terminology can also function to signal solidarity with trans and nonbinary people, as well as convey the radical idea that our traditional understanding of sex is outdated.

The shift to “sex assigned at birth” may be well intentioned, but it is not progress. We are not against politeness or expressions of solidarity, but “sex assigned at birth” can confuse people and creates doubt about a biological fact when there shouldn’t be any. Nor is the phrase called for because our traditional understanding of sex needs correcting — it doesn’t.

This matters because sex matters. Sex is a fundamental biological feature with significant consequences for our species, so there are costs to encouraging misconceptions about it.

Sex matters for health, safety and social policy and interacts in complicated ways with culture. Women are nearly twice as likely as men to experience harmful side effects from drugs, a problem that may be ameliorated by reducing drug doses for females. Males, meanwhile, are more likely to die from Covid-19 and cancer, and commit the vast majority of homicides and sexual assaults . We aren’t suggesting that “assigned sex” will increase the death toll. However, terminology about important matters should be as clear as possible.

More generally, the interaction between sex and human culture is crucial to understanding psychological and physical differences between boys and girls, men and women. We cannot have such understanding unless we know what sex is, which means having the linguistic tools necessary to discuss it. The Associated Press cautions journalists that describing women as “female” may be objectionable because “it can be seen as emphasizing biology,” but sometimes biology is highly relevant. The heated debate about transgender women participating in female sports is an example ; whatever view one takes on the matter, biologically driven athletic differences between the sexes are real.

When influential organizations and individuals promote “sex assigned at birth,” they are encouraging a culture in which citizens can be shamed for using words like “sex,” “male” and “female” that are familiar to everyone in society, as well as necessary to discuss the implications of sex. This is not the usual kind of censoriousness, which discourages the public endorsement of certain opinions. It is more subtle, repressing the very vocabulary needed to discuss the opinions in the first place.

A proponent of the new language may object, arguing that sex is not being avoided, but merely addressed and described with greater empathy. The introduction of euphemisms to ease uncomfortable associations with old words happens all the time — for instance “plus sized” as a replacement for “overweight.” Admittedly, the effects may be short-lived , because euphemisms themselves often become offensive, and indeed “larger-bodied” is now often preferred to “plus sized.” But what’s the harm? No one gets confused, and the euphemisms allow us to express extra sensitivity. Some see “sex assigned at birth” in the same positive light: It’s a way of talking about sex that is gender-affirming and inclusive .

The problem is that “sex assigned at birth”— unlike “larger-bodied”— is very misleading. Saying that someone was “assigned female at birth” suggests that the person’s sex is at best a matter of educated guesswork. “Assigned” can connote arbitrariness — as in “assigned classroom seating” — and so “sex assigned at birth” can also suggest that there is no objective reality behind “male” and “female,” no biological categories to which the words refer.

Contrary to what we might assume, avoiding “sex” doesn’t serve the cause of inclusivity: not speaking plainly about males and females is patronizing. We sometimes sugarcoat the biological facts for children, but competent adults deserve straight talk. Nor are circumlocutions needed to secure personal protections and rights, including transgender rights. In the Supreme Court’s Bostock v. Clayton County decision in 2020, which outlawed workplace discrimination against gay and transgender people, Justice Neil Gorsuch used “sex,” not “sex assigned at birth.”

A more radical proponent of “assigned sex” will object that the very idea of sex as a biological fact is suspect. According to this view — associated with the French philosopher Michel Foucault and, more recently, the American philosopher Judith Butler — sex is somehow a cultural production, the result of labeling babies male or female. “Sex assigned at birth” should therefore be preferred over “sex,” not because it is more polite, but because it is more accurate.

This position tacitly assumes that humans are exempt from the natural order. If only! Alas, we are animals. Sexed organisms were present on Earth at least a billion years ago, and males and females would have been around even if humans had never evolved. Sex is not in any sense the result of linguistic ceremonies in the delivery room or other cultural practices. Lonesome George, the long-lived Galápagos giant tortoise , was male. He was not assigned male at birth — or rather, in George’s case, at hatching. A baby abandoned at birth may not have been assigned male or female by anyone, yet the baby still has a sex. Despite the confusion sown by some scholars, we can be confident that the sex binary is not a human invention.

Another downside of “assigned sex” is that it biases the conversation away from established biological facts and infuses it with a sociopolitical agenda, which only serves to intensify social and political divisions. We need shared language that can help us clearly state opinions and develop the best policies on medical, social and legal issues. That shared language is the starting point for mutual understanding and democratic deliberation, even if strong disagreement remains.

What can be done? The ascendance of “sex assigned at birth” is not an example of unhurried and organic linguistic change. As recently as 2012 The New York Times reported on the new fashion for gender-reveal parties, “during which expectant parents share the moment they discover their baby’s sex.” In the intervening decade, sex has gone from being “discovered” to “assigned” because so many authorities insisted on the new usage. In the face of organic change, resistance is usually futile. Fortunately, a trend that is imposed top-down is often easier to reverse.

Admittedly, no one individual, or even a small group, can turn the lumbering ship of English around. But if professional organizations change their style guides and glossaries, we can expect that their members will largely follow suit. And organizations in turn respond to lobbying from their members. Journalists, medical professionals, academics and others have the collective power to restore language that more faithfully reflects reality. We will have to wait for them to do that.

Meanwhile, we can each apply Strunk and White’s famous advice in “The Elements of Style” to “sex assigned at birth”: omit needless words.

Alex Byrne is a professor of philosophy at M.I.T. and the author of “Trouble With Gender: Sex Facts, Gender Fictions.” Carole K. Hooven is an evolutionary biologist, a nonresident senior fellow at the American Enterprise Institute, an associate in the Harvard psychology department, and the author of “T: The Story of Testosterone, the Hormone That Dominates and Divides Us.”

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

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Mount Everest was the riskiest place I had practiced medicine until I became an OB/GYN in the South

In post-dobbs georgia, unlike on everest, i didn't choose the restrictions and threats i now practice under, by mimi zieman.

On the eastern glacier of Everest in Tibet, where avalanches boomed in the distance and icy winds blew through my nylon tent, I tucked in at night within a cocoon of uncertainty. I kept my stethoscope and blood pressure cuff nestled by my thighs to keep them warm and ready to use. Months stretched out in isolation with me on high alert — alone in my medical role — fearing I’d fail when most needed. Most nights I shivered as I donned my down layers, slept with two hats, and tucked a hot water bottle beside my feet for warmth. I envied the rest of the all-male team who slept bare.

In the middle of one night, my fears became reality. Two severely injured climbers crawled over uneven rocks to stumble into camp. They shouted our names for help, piercing the black air. Half asleep, with shoelaces untied and blades of hail stinging my face, I stumbled toward the sound of their voices, then helped them back to our tents, and began a marathon of care. At 18,000 feet, the thin air mirrored my nascent experience as a 25-year-old medical student. I worried about their conditions and the care I was delivering. Was I doing everything correctly? Remembering the protocols? What else should I be doing?  

My journey to Everest was a leap of faith. I was raised a New York City girl and felt like an unlikely candidate for a Himalayan expedition, but I couldn’t resist the call of the mountains. Once I joined the team as the Medical Officer, I dove into mountaineering medicine, sought counsel from experts, and armed myself with knowledge. Yet nothing could prepare me for how isolated we’d be. We saw no outsiders for months and knew there was no chance for rescue on the East Face of the mountain in Tibet. 

A few days later, back in Base Camp, I laid out packages of gauze, tape, scissors, antiseptic and checked the antibiotics on hand. While tending to a climber with severe frostbite injuries affecting both hands and feet, I tipped his hat over his eyes and suggested he look away. I removed the bandage I’d placed at Advanced Base Camp from his first finger. A shrunken black stub of a distal phalanx — the whole tip of his finger — stared back. He lifted his hat, saw his finger, and looked up at me with wide eyes. Then he rounded his back away from me like an animal curled up in defense. More unwrapping, more fingers, more rocking with sobs, digit after digit, dead, inch-long black fingertips. He wailed, shook his head, and his sobs pierced my heart. I wished I could protect him from this pain. His eyes were pleading, but I had no answers. I, too, was surprised at how rapidly his shredded fingers had turned to coal.

Since the Dobbs decision, I don’t have the autonomy I had on the mountain to deliver the best care possible.

“Will I ever be able to climb again?” he asked. The gauze adhered to his final two fingers. 

I didn’t have an answer.

My only motivation was to provide the best care possible while being present with compassion. We were all at the knife edge of our limits and digging deeply for strength.

Each of us on that mountain had weighed our risks and vulnerabilities and had chosen to be there. The climbers had chosen the extreme challenge of Everest and did everything in their power to remain alive. I had chosen to work in these circumstances and was delivering the best care I could under difficult conditions.

Not so in my OB/GYN practice in Georgia. Since the Dobbs decision, I don’t have the autonomy I had on the mountain to deliver the best care possible. This is a different kind of isolation, and it’s more unnerving. Despite years of medical training and a commitment to evidence-based care, physicians are hamstrung by state laws, and our patients are suffering. 

A few weeks ago, I entered an exam room to find a young woman staring at her phone, wearing a college sweatshirt and crocs decked out with charms. She had driven alone to Georgia from Tennessee seeking an abortion. Georgia law permits abortions  until approximately two weeks after a missed period, whereas Tennessee bans all procedures with narrow medical emergency exceptions .

After discussing how she felt and clarifying information in her medical history, I said, “Your ultrasound doesn’t show a pregnancy in the uterus, which can happen for a few reasons, most commonly because it’s too early in pregnancy. But the level of pregnancy hormone in your blood and medical history makes me concerned you could have an ectopic pregnancy — one that grows outside the uterus, typically in the fallopian tubes.”

Here, the peaks are legal hurdles, the valleys emotional.

We discussed what might be going on and the next steps we could take, but this young woman dissolved into tears. Getting advanced care to rule out an ectopic pregnancy would require involving her health insurance, which would alert her parents, something she wanted to avoid. I left the room to give her space and time to compose herself while I went to investigate options for care. 

Sobbing patients overwhelmed by difficult decisions resulting from abortion restrictions are now part of our everyday practice as OB/GYNs. We’re not discussing plans of care based on science — we’re sorting out travel, logistics, time off work, childcare, emotional distress, and legal ramifications. Here, the peaks are legal hurdles, the valleys emotional.

This is taking a toll on us. A recent survey by EL Sabbath et al. of OB/GYNs in states with bans documents immense personal impacts “including distress at having to delay essential patient care, fears of legal ramifications, mental health effects, and planned or actual attrition.” The majority reported symptoms of anxiety or depression as a direct consequence of Dobbs. Ninety-three percent of respondents had situations where they or their colleagues could not follow standard of care. Eleven percent had already moved to another state without restrictions, and 60% considered leaving but have family and other obligations making them stay for now.

Although we’ve spent years in medical training, our expertise has been erased by politicians with no medical background. Not being able to practice in accordance with the ethical principles of respecting patient privacy and autonomy in the decision-making process is wounding us.

A May 2023 survey found that 55% of Idaho OB-GYNs were seriously or somewhat considering leaving the state due to the abortion ban, and a hospital there was forced to close its labor and delivery unit due to related staffing issues. Fewer OB/GYNS means less maternal care and yet many of the states with abortion restrictions have the highest maternal mortality rates.

Take this a step back and medical trainees are being affected. Abortion bans are affecting almost half of OB/GYN training programs. A recent survey of medical students in Indiana found 70% were less likely to pursue residency in a state with abortion bans. With decreased training — and diminishing numbers of OB/GYNs willing to practice in these states —  maternal mortality will rise. Care of other gynecological conditions such as endometriosis, infertility, fibroids and cancer will suffer. This affects the most vulnerable among us, low-income and minority patients.

My patient’s insurance would only work in Tennessee. She reminded me of my youngest daughter. I couldn’t picture her processing this information on her own. I was most worried that my patient would need to drive herself back across state lines in this fraught emotional state.

Unlike my experience on Everest, I am not choosing these risks — to my patients or to myself — of practicing under untenable circumstances where I cannot deliver optimal care.

She returned to Tennessee, where her bloodwork confirmed an ectopic pregnancy. Even though treatment of ectopic pregnancies is permitted in that state, the hospital released her without immediate treatment. Delayed care could put her at risk for impaired future fertility, emergency rather than elective surgery, and even death. I can only hope none of that happened. Treating people crossing state lines, who we cannot adequately care for ourselves, is stressful. I still think of her.

I’ve also been thinking a lot about the decision I made to go to Everest with the risks involved and the potential for trauma. I’d joined the team to experience the majesty of the Himalayas. To wake up to fine blue mountain light, live within vastness, and quell the warnings from girlhood to stay small and be safe. To this end, I made peace with the risks I was taking and ultimately grew from facing my fears. When trauma beset us, each team member grew into the best version of themselves.

My family moved to Georgia almost three decades ago, a different kind of unlikely for this city-raised girl. I grew to love the rolling hills of north Georgia, the breathtaking palette of autumn, the scent of apple cider and boiled peanuts. I learned how to cook collards — without ham — their rough stems of veins running through me.

But in the South now, we are not expanding and growing; we are shrinking, boxed in by medical practice governed by legislators, lawyers and hospital administrators. 

Unlike my experience on Everest, I am not choosing these risks — to my patients or to myself — of practicing under untenable circumstances where I cannot deliver optimal care. If I were finishing my training today and choosing somewhere to practice, I would not come to this state or anywhere with these restrictions on practice. 

I would never have predicted, when I was shivering, afraid, and alone providing care on the mountain, that I would feel threatened 36 years later by simply practicing basic healthcare in America. I couldn’t have known that after studying and working hard, I would not be able to put my education, knowledge, and skills to their best use. That I would be hampered when fulfilling the essence of my dream to care for women with skill and compassion. I couldn’t have known how alone, isolated and abandoned I would feel. Right here, at home. 

about this topic

• As more abortion bans occur, many patients must travel hundreds of miles for care — or be stranded
• Yes, some medication abortion patients go to the ER — but it may not be for what you think
• Supreme Court restricting mifepristone would be a "slippery slope" for future drugs

Mimi Zieman MD is the author of " Tap Dancing on Everest " (Falcon, April 2024), and "The Post-Roe Monologues," a play that has been performed in multiple cities. A physician, she has also co-authored sixteen editions of "Managing Contraception." Her writing has appeared in Newsweek, The Sun Magazine, Ms. Magazine, The Forward, NBC News THINK, Dorothy Parker’s Ashes, and other publications.

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Mental health care is hard to find, especially for people with Medicare or Medicaid

Rhitu Chatterjee

With rates of suicide and opioid deaths rising in the past decade and children's mental health declared a national emergency , the United States faces an unprecedented mental health crisis. But access to mental health care for a significant portion of Americans — including some of the most vulnerable populations — is extremely limited, according to a new government report released Wednesday.

The report, from the Department of Health and Human Services' Office of Inspector General, finds that Medicare and Medicaid have a dire shortage of mental health care providers.

The report looked at 20 counties with people on Medicaid, traditional Medicare and Medicare Advantage plans, which together serve more than 130 million enrollees — more than 40% of the U.S. population, says Meridith Seife , the deputy regional inspector general and the lead author of the report.

Medicaid serves people on low incomes, and Medicare is mainly for people 65 years or older and those who are younger with chronic disabilities.

The report found fewer than five active mental health care providers for every 1,000 enrollees. On average, Medicare Advantage has 4.7 providers per 1,000 enrollees, whereas traditional Medicare has 2.9 providers and Medicaid has 3.1 providers for the same number of enrollees. Some counties fare even worse, with not even a single provider for every 1,000 enrollees.

"When you have so few providers available to see this many enrollees, patients start running into significant problems finding care," says Seife.

The findings are especially troubling given the level of need for mental health care in this population, she says.

"On Medicare, you have 1 in 4 Medicare enrollees who are living with a mental illness," she says. "Yet less than half of those people are receiving treatment."

Among people on Medicaid, 1 in 3 have a mental illness, and 1 in 5 have a substance use disorder. "So the need is tremendous."

The results are "scary" but "not very surprising," says Deborah Steinberg , senior health policy attorney at the nonprofit Legal Action Center. "We know that people in Medicare and Medicaid are often underserved populations, and this is especially true for mental health and substance use disorder care."

Among those individuals able to find and connect with a provider, many see their provider several times a year, according to the report. And many have to drive a long way for their appointments.

"We have roughly 1 in 4 patients that had to travel more than an hour to their appointments, and 1 in 10 had to travel more than an hour and a half each way," notes Seife. Some patients traveled two hours each way for mental health care, she says.

Mental illnesses and substance use disorders are chronic conditions that people need ongoing care for, says Steinberg. "And when they have to travel an hour, more than an hour, for an appointment throughout the year, that becomes unreasonable. It becomes untenable."

"We know that behavioral health workforce shortages are widespread," says Heather Saunders , a senior research manager on the Medicaid team at KFF, the health policy research organization. "This is across all payers, all populations, with about half of the U.S. population living in a workforce shortage."

But as the report found, that's not the whole story for Medicare and Medicaid. Only about a third of mental health care providers in the counties studied see Medicare and Medicaid patients. That means a majority of the workforce doesn't participate in these programs.

This has been well documented in Medicaid, notes Saunders. "Only a fraction" of providers in provider directories see Medicaid patients, she says. "And when they do see Medicaid patients, they often only see a few."

Lower reimbursement rates and a high administrative burden prevent more providers from participating in Medicaid and Medicare, the report notes.

"In the Medicare program, they set a physician fee rate," explains Steinberg. "Then for certain providers, which includes clinical social workers, mental health counselors and marriage and family therapists, they get reimbursed at 75% of that rate."

Medicaid reimbursements for psychiatric services are even lower when compared with Medicare , says Ellen Weber , senior vice president for health initiatives at the Legal Action Center.

"They're baking in those discriminatory standards when they are setting those rates," says Steinberg.

The new report recommends that the Centers for Medicare & Medicaid Services (CMS) take steps to increase payments to providers and lower administrative requirements. In a statement, CMS said it has responded to those recommendations within the report.

According to research by Saunders and her colleagues at KFF, many states have already started to take action on these fronts to improve participation in Medicaid.

Several have upped their payments to mental health providers. "But the scale of those increases ranged widely across states," says Saunders, "with some states limiting the increase to one provider type or one type of service, but other states having rate increases that were more across the board."

Some states have also tried to simplify and streamline paperwork, she adds. "Making it less complex, making it easier to understand," says Saunders.

But it's too soon to know whether those efforts have made a significant impact on improving access to providers.

CMS has also taken steps to address provider shortages, says Steinberg.

"CMS has tried to increase some of the reimbursement rates without actually fixing that structural problem," says Steinberg. "Trying to add a little bit here and there, but it's not enough, especially when they're only adding a percent to the total rate. It's a really small increase."

The agency has also started covering treatments and providers it didn't use to cover before.

"In 2020, Medicare started covering opioid treatment programs, which is where a lot of folks can go to get medications for their substance use disorder," says Steinberg.

And starting this year, Medicare also covers "mental health counselors, which includes addiction counselors, as well as marriage and family therapists," she adds.

While noteworthy and important, a lot more needs to be done, says Steinberg. "For example, in the substance use disorder space, a lot of addiction counselors do not have a master's degree. And that's one of their requirements to be a counselor in the Medicare program right now."

Removing those stringent requirements and adding other kinds of providers, like peer support specialists, is key to improving access. And the cost of not accessing care is high, she adds.

"Over the past two decades, [in] the older adult population, the number of overdose deaths has increased fourfold — quadrupled," says Steinberg. "So this is affecting people. It is causing deaths. It is causing people to go to the hospital. It increases [health care] costs."

• Centers for Medicare & Medicaid Services
• mental health

Opinion What we have learned about the Supreme Court’s right-wingers

Supreme Court observers frequently refer to its right-wing majority of six as a single bloc. However, differences among those six have become more apparent over time. Justices Samuel A. Alito Jr.’s and Clarence Thomas’s extreme judicial activism, partisan screeds and ethics controversies put them in a category unto themselves. Meanwhile, Justice Amy Coney Barrett has demonstrated surprising independence.

Watch Justice Barrett.

Not all Republican-appointed judges are the same. In Trump v. Anderson (concerning disqualification under Section 3 of the 14th Amendment of four-times-indicted former president Donald Trump), for example, Barrett, along with Justices Elena Kagan, Ketanji Brown Jackson and Sonia Sotomayor, criticized the maximalist majority opinion, which held that not only could state courts not determine disqualification but that Congress had to act before any candidate could be disqualified from federal office.

Like the so-called liberal justices, Barrett was disinclined to address “the complicated question whether federal legislation is the exclusive vehicle through which Section 3 can be enforced.” The court decided too much, she agreed. Her complaint with the so-called liberal justices was primarily tonal. (“This is not the time to amplify disagreement with stridency.”)

Likewise, in United States v. Texas (considering the stay on enforcement of Texas’s S.B. 4 immigration law ), Barrett, along with Justice Brett M. Kavanaugh, offered the U.S. Court of Appeals for the 5th Circuit an opening to take up the case promptly, which it did, rather than wade into a procedural fight over a stay in a case concerning Texas’s constitutionally suspect law.

As Supreme Court expert Steve Vladeck put it , “The Barrett/Kavanaugh concurrence went out of its way to nudge the Fifth Circuit — noting not only that the Fifth Circuit should be able to rule on the stay pending appeal ‘promptly,’ but that, ‘If a decision does not issue soon, the applicants may return to this Court.’” In essence, Barrett said the Supreme Court would not meddle in a circuit’s administrative business. But if the 5th Circuit actually allowed this constitutional monstrosity to proceed, she would have a different view.

And in Moore v. Harper (the independent state legislature doctrine), Barrett joined in the chief justice’s majority opinion, along with the three Democratic-appointed justices, to bat down the radical notion that state courts have no role in determining alleged violations of state election laws (provided they did “not transgress the ordinary bounds of judicial review”).

Beyond her opinions in high-profile cases, Barrett also sought to repair the court’s reputation damaged by right-wing partisanship. She has started appearing alongside Sotomayor publicly to insist that the court’s ideological combatants are more collegial than they might appear. Perhaps she is.

Barrett is no Sandra Day O’Connor (a true swing justice). Barrett was just as extreme on Roe v. Wade as the other right-wingers. Nevertheless, her efforts to carve an independent niche on the court should not be ignored.

On the other hand, there is no limit to what Justices Alito and Thomas will do.

In contrast to Barrett, no right-wing theory or activist invitation is too wacky for Alito and Thomas to entertain.

During oral argument on Danco Laboratories v. Alliance for Hippocratic Medicine (considering the Food and Drug Administration’s approval of mifepristone), Alito and Thomas took up the right-wing infatuation with the Comstock Act , passed in 1873. Alito, alone among the justices, seemed anxious to speed past the very real “standing” issue to ruminate about a means of banning abortion nationwide.

The Comstock law, which has not been enforced in about a century, bans sending “every article, instrument, substance, drug, medicine, or thing which is advertised or described in a manner calculated to lead another to use or apply it for producing abortion .” (Also, certainly unconstitutionally, it bans a large category of vaguely defined pornography.) Thomas and Alito seem ready and willing to deploy the law in a way it has never been applied: namely, to states where abortion is otherwise legal, thereby threatening the availability of medical abortions nationwide.

The Post reported , “Some experts and Biden officials fear Alito and Thomas are planning to write a separate opinion focused solely on the Comstock Act, arguing that the law remains viable and providing legal cover to a future administration that seeks to invoke it.” Even if Alito and Thomas do not carry the day, the Hill reported , “access to abortion pills could still very much be at risk if Alito and Thomas succeed in soliciting a Comstock-focused challenge in the future,” abortion rights defenders fear. A future Republican administration might well start trying to employ the law to throw abortion providers in jail.

Fishing for a hook to extrapolate the Dobbs v. Jackson Women’s Health Organization ruling into a nationwide ban on medical abortions epitomizes these justices’ radical disregard for precedent and brazen judicial activism. Indeed, Alito and Thomas increasingly seem like stalking horses for the far-right agenda, be it on guns, abortion or voting.

The Supreme Court’s credibility

Numerous polls show the court’s approval has cratered , likely a function of its ethics scandals, partisan rhetoric and aggressive reversal of precedent. In other words, judicial imperialism and disdain for ethical rules that apply even to members of Congress are unpopular with voters.

Increasingly partisan Thomas and Alito no longer bother to conceal their contempt for ethical restrictions , congressional oversight or judicial temperament . They have repeatedly failed to disclose luxurious gifts (with no sign of remorse) and remain adamant that they will accept no outside oversight.

After a firestorm of protest over financial disclosure lapses, Chief Justice John G. Roberts Jr. released ethical guidelines so weak that they lack an enforcement mechanism. Worse, the guidelines are so porous that they posed no barrier to Thomas sitting on cases involving attempts to overturn the 2020 election that his wife supported.

Unless the rest of the court decides to restrain Thomas and Alito, concerns about ethical lapses and misalignment with contemporary American values will deepen, heightening demands for congressional responses (e.g., mandatory ethics, term limits, court expansion). If that happens, Alito and Thomas will be largely responsible.

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Solar eclipse and the quantum leap of medicine.

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Gold Balls, Porcelain, 24K Gold Plated, Variable Sizes by Mosh Kashi. Photography: Elad Sarig // For ... [+] me, alignment is just a point of view. Each of my stories includes an original artwork. Clicking on them will take you to their websites. I am grateful to the artists for sharing their work.

Monday’s solar eclipse is a special celestial event, reflecting the interconnectedness of nature, involving the alignment of Earth, moon and sun. This alignment can be viewed only from specific geographical locations on Earth. In other words, the state of the viewer influences the experienced phenomenon.

In the same way, in quantum mechanics the observer influences the nature of the observed reality. This is no different from well-being, always influenced by our own perception.

Medicine is ever changing; the discovery of penicillin, development of vaccines, invention of MRI machines – each step has transformed our practice. But now, yet unbeknownst to most, the biggest leap of all is underway. Quantum computing will challenge what we know about medicine, how we conceive health and how we advance it. A completely new, or de novo, mutation in the evolutionary chain of medicine. This is an exciting time; ushering in the alignment of machine learning and quantum computing in healthcare.

Leveraging the principles of quantum mechanics, quantum computing is predicted to outperform conventional supercomputers, allowing unimaginable processing prowess . But it goes much deeper than power and speed; it all starts at the fundamental unit of operation – the qubit. Unlike traditional computers, relying on the dichotomic bits, the qubit can actually be in two states at the same time, encoding data of 0 and 1 simultaneously – representing multiple combinations of possibilities. This stems from the elemental quantum principle of superposition, whereby subatomic particles, like electrons, exist everywhere, all the time, at varying probabilities. It allows quantum systems to exponentially increase their computing capacity, as they inherently consider multiple possibilities.

Beyond superposition, the quantum principle of entanglement has astounded physicists throughout history and is no less astonishing philosophically. It means qubits are intrinsically interlinked, or entangled, such that the state of one qubit influences that of another – even at vast distances. This allows for interconnected systems, efficiently computing together, according to their intrinsically linked nature.

Health research and innovation has undoubtedly been advancing rapidly with AI, but the promise of true precision medicine has yet to arrive. First, we must acknowledge the richness and complexity of data needed to truly create personalized medical models.

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In my opinion, a paradigm shift is needed; all data is medical data. Our medical history, intertwined with our nutrition, the environmental conditions we have been exposed to (such as pollution and temperature), physical activity, genetic and epigenetic makeup including social habits – everything impacts our health. In other words, our health is intrinsically entangled in all other aspects of our being. If we cannot model it – we won’t be able to make the leap forward with AI, as “big data” will always be somewhat small data, omitting crucial determinants of health.

Quantum computing has the potential to analyze the complex data interplay of biological systems while also supporting it computationally. This was the premise for IBM and Cleveland Clinic’s unveiling of the first quantum computing dedicated to health a year ago. This past week, Microsoft announced possible groundbreaking news: an error-correction algorithm for quantum computing, yet to be proven in real-life medical applications. The problem of calculation errors is a major one, as with their great promise, qubits are highly susceptible to error, sensitive to disturbances from vibration or temperature , known as noise . Reliable calculations are key to move forward, especially in the medical world where life is at stake.

Until then, we must rely on our physicians to differentiate signal from noise and allow a safe space to consider multiple possibilities that finally collapse into one decision.

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Ethical Issues of Artificial Intelligence in Medicine and Healthcare

Dariush d. farhud.

1. School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

2. Department of Basic Sciences/Ethics, Iranian Academy of Medical Sciences, Tehran, Iran

3. Farhud Genetic Clinic, Tehran, Iran

Shaghayegh Zokaei

4. School of Advanced Medical Sciences, Tehran Medical Branch, Islamic Azad University, Tehran, Iran

Introduction

Artificial intelligence (AI) is a term applied to a machine or software and refers to its capability of simulating intelligent human behavior, instantaneous calculations, problem-solving, and evaluation of new data based on previously assessed data ( 1 ). AI heavily influences many industries and fields, including agriculture and farming, manufacturing and production, autonomous vehicles, fashion, sports analytics and activities, healthcare, and the medical system. This technology has the power to impact the future of the industry and human beings, but it is a double-edged sword.

AI applications in healthcare have literally changed the medical field, including imaging and electronic medical records (EMR), laboratory diagnosis, treatment, augmenting the intelligence of the physicians, new drug discovery, providing preventive and precision medicine, biological extensive data analysis, speeding up processes, data storage and access for health organizations. However, this field of science faces various ethical and legal challenges. Despite tremendous strides made in the field of AI in communities, and its role in improving the treatment process, it is not accessible to all societies. Many low-income and developing countries still do not have access to the latest technologies. It should be noted that the ethical dilemmas, privacy and data protection, informed consent, social gaps, medical consultation, empathy, and sympathy are various challenges that we face in using AI. Therefore, before integrating artificial intelligence with the healthcare system, practitioners and specialists should consider all four medical ethics principles, including autonomy, beneficence, nonmaleficence, and justice in all aspects of health care ( 2 – 6 ) ( Fig. 1 ) ( 7 , 8 ).

Tommy, the robot nurse, helps keep flesh-and-blood doctors and nurses safe from coronavirus at the Circolo Hospital in Varese, Italy ( 7 , 8 )

Privacy and Data Protection

General Data Protection Regulation (GDPR) was first enacted by the European Union (EU), as it amended the privacy legislation in other countries, such as the US and Canada. According to these regulations, all personal data and the activities of foreign communities and companies are processed by the union-based data processor or controller in order to protect the information of natural persons with sufficient protection ( 9 ). In the United States, the Genetic Information Non-discrimination Acts (GINA) is an organization that prohibits employers from discriminative decisions according to the genetic health information of individuals ( 10 ). In fact, the role of AI in healthcare is to analyze consumer health data and medical device images, improve diagnoses and outcomes, as well as a helpful role in accelerating health research activities.

In addition, social media, as part of AI, play a vital role in disseminating health news or medical advice, especially in pandemics. However, these can be ostensible positive aspects of AI, and ensuring the safety of the patients' data is still a significant concern when using robots:

• In healthcare, current laws are not enough to protect an individual’s health data.
• Clinical data collected by robots can be hacked into and used for malicious purposes that minimize privacy and security.
• Some social networks gather and store large amounts of users’ data, for instance, individuals’ mental health data, without their consent, which can be helpful in the marketing, advertising, and sales of these companies.
• Also, some genetics testing and bioinformatics companies, which are not legal or closely monitored, sell customer data to pharmaceutical and biotechnology companies.

Informed Consent and Autonomy

Informed consent is a process of communication between a patient and health care provider, which includes decision capacity and competency, documenting informed consent, and ethical disclosure ( 11 ). According to the definition of ethical responsibility, patients have the right to be informed of their diagnoses, health status, treatment process, therapeutic success, test results, costs, health insurance share or other medical information, and any consent should be specific per purpose, be freely given, and unambiguous. Concerns about this issue also increased with the rise of AI in healthcare applications ( 12 ). Based on the autonomy principle:

• All individuals have the right to get information and ask questions before procedures and treatments.
• Patients should be able to be aware of the treatment process, the risks of screening and imaging, data capture anomalies, programming errors, the privacy of data and access control, safeguarding a considerable quantity of the genetic information obtained through genetic testing.
• Patients may refuse treatment that the health care provider deems appropriate.
• Patients have the right to know who should be responsible when these robotic medical devices fail or errors. The answer is essential for both patient rights and the medical labor market.

Social Gaps and Justice

Another problem that threatens societies following the development of AI is the social gap issue. In all countries around the world, with every development, discovery and invention, people face greater social inequality and less social justice. Although AI improves the accessibility to more information about science and technology, world events, climate changes, and politics around the world, it exacerbates social inequality ( 13 ), as mentioned below:

• Automation and advanced economies have widened the gap between developing and advanced countries.
• Many people lose their jobs as robots grow and develop.
• Bookkeepers and managers in different communities could lose their jobs with the increase of automated systems, and there will be a considerable decrease in salaries.
• The rise of surgical robots and robotic nurses in healthcare environment, operating instead of surgeons and caring for patients instead of nurses, threatens their future job opportunities.

Medical Consultation, Empathy, and Sympathy

Integrating artificial intelligence (AI) with all areas of health care seems difficult and impossible. Due to uniquely human emotions, human and medical robots might not evolve together in a short time. Physicians and other care providers should seek consultation from or provide consultation to their colleagues, which is not possible in autonomous (robotic) systems. On the other hand, it seems unlikely that patients will accept “machine-human” medical relations instead of “human-human.” Doctors and nurses are expected to provide treatment in an empathetic and compassionate environment, which will significantly affect the healing process of patients. This will not be achieved with robotic physicians and nurses. Patients will lose empathy, kindness, and appropriate behavior when dealing with robotic physicians and nurses because these robots do not possess human attributes such as compassion. This is one of the most significant negative aspects of artificial intelligence in medical science. For instance:

• In Obstetrics and Gynecology, any clinical examination requires a sense of compassion and empathy, which will not be achieved with robotic doctors.
• Children usually experience fear or anxiety as they engage in healthcare settings and meet professionals. Their behavioral manifestations are lack of cooperation, withdrawal, and aggression that could be uncontrollable with the new robotic medicine system.

India’s robots such as Mitra are being used to reduce the risk of infection for medical staff and taking care of Covid-19 patients ( 14 )

In brief, the rapid advancement of Artificial intelligence (AI) in the clinical and biomedical fields is considered a great approach in many communities that may augment professionals in the healthcare system. Nevertheless, despite the great potential and advancement of AI in the field of medical and health care, this achievement has imposed new requirements in the field of medical ethics. Consequently, we should be aware that its negative aspects might outweigh its benefits. To overcome this problem, experts must consider humanity and ethics in this regard.

Conflict of interest

The authors declare that there is no conflict of interests.