"Ethics" has replaced Mom, the flag, and apple pie as something one must not only "be for" these days, but appear to "be doing something about". We may not be able to define ethics, especially to the Federal Trade Commission (FTC) examiners, but everyone has an opinion about them. To the traditional thinkers they are established by the laws of nature, community mores, and male logic, as only the last thirty years have had the benefit of female opinion, as explained below.

Most people carry a set of biased values that have been learned, either due to personal experiences, or as family doctrine experienced between ages two and twelve. There is bad bias and good bias, as well as situational bias. The difference is recognizing that a value is based on bias of unknown origin versus a true personal belief. Bias is most often just an evaluative premise, without true factual basis. Open discussion will determine if it applies to the situation at hand, or the team involved in the discussion. As students, ethics are often only explained as legal terms, black and white, yes or no, good or bad behavior. Life is not that easy, but some presenters do not want to enter the harder aspect of bio-ethics, so they leave it as the legal rulings of history. Many aren't even sure whether the word "ethics" is singular or plural, but we seem to know it when we see it, or at least that is what the discussions seem to indicate at any meeting of two or more veterinarians.

An historical overview may be helpful to understand how we got to where we are today in ethical theories, medical ethics, and bio-ethical discussions:

 Greeks and the virtues:
The ancient Greek Philosophers, Socrates, Plato, and Aristotle, as well as the Athenian general culture of fifth-century B.C.E. (before common era), advocated virtue ethics, which is acquiring the good traits of character. The Greek word ethos meant disposition/character. Ethike aretai means "skills of character", and the Greek word arete means "excellence". During pre-Socratic Greek ethics in the eighth century B.C.E., Homer emphasized ethike arete as performing one's role well. The Greek ethics also did this, and when defining "good" or "excellence", they would ask, "What is the purpose of the role?", but then also asked, "What virtues should a good physician possess?" Role-defined ethics have existed in medicine to the current day. Hippocrates adopted patient-centered ethics, and included a sanctity-of-all-life world view. It should also be noted that Socratic virtues also celebrated an elitist, anti-democratic ethics that scorned the ordinary person and his worth. The Greeks believed they were superior to those whom they conquered. Aristotle's student Alexander the Great had no tolerance for the culture, values, and language of others. His ethics were perfectionist in nature, ergo everything must become Greek.

 Christian ethics and virtue
By the fourth century C.E. (current era, formerly A.D.), Christianity had added its theological virtues of faith, hope, and charity to the list of human virtues. The pragmatic virtue of compassion (charity) comes in part from Christianity's emphasis on helping others. The etymological root of "compassion" means "to suffer with". The Greek physicians emphasized technical competence in curing disease, while the religious physicians emphasized compassion in being with patients. When the limits of technical competence appeared to have been reached, as they were so often done in these early centuries, compassion became the supreme virtue. In contrast to the Greek elitism, the three great religions of the West emphasized duties to the poor and sick. The physician's license, knowledge, and wisdom were no longer a proprietary right to make money, but rather, a higher calling from the supreme deity.

 Natural law theory:
When the Romans conquered Greece, during the second century B.C.E., the Stoic philosophers of Roman times elevated one aspect of the Greek world view to a higher level. Rules for human beings were so embedded in the texture of the world that they were "law" for humans. These became known as "natural laws", since they could be apprehended by unaided reason, without scripture or divine revelation. In the fourth century C.E., St. Augustine taught that human nature was contaminated by sin and, as such, human feelings were mired in lust, sloth, avarice, and the other deadly sins. In the eleventh century, Thomas Aquinas synthesized many aspects of Aristotelianism with the orthodox teaching of Christians. Aquinas made an explicit connection between God and the natural laws of the world. A rational God made the world work rationally and gave humans reason to discover his rational, natural laws. Aquinas also held that thinking about ethics was emphatically not about examining one's feelings, but rather following rules laid down by God and his agents, the clergy and theologians.

 The natural law theory bequeathed to medical ethics the doctrine of double effect. This doctrine holds that if an action had two effects, one good and the other evil, the action was morally permitted: a) if the action was good in itself, or not evil; b) if the good followed as immediately from the cause, as did the evil effect; c) if only the good effect was intended; and d) if there was as an important reason for performing the action, as for allowing the evil effect. As an example, consider an ectopic pregnancy, where the embryo grows in the fallopian tube, or a cancerous uterus, where the uterus was gravid, and both had to be removed together, the rule banning abortion would allow it to be put into abeyance.

 The natural law tradition also gives rise to the principle of totality, which covers what kind of changes may be made to the human body. Changes are permitted only to ensure the proper functioning of the total body. Thus the principle of totality rules out all forms of sterilization to prevent pregnancy, and forbids cosmetic surgery solely to change one's appearance.

 Social contract theories
These are often called "contractarianism", are essentially secular, and independent of a belief in a supreme deity. It assumes that people are fundamentally self-interested and that moral rules have evolved for humans to get along with one another. Social contract does not separate ethics from politics. Hypothetical political bargaining is viewed as the foundation of the kind of behavior that is allowed as ethical.

 Libertarians favor a government for defense, and for very limited public works. National parks, interstate highways, public hospitals, food stamps, welfare, and other programs that force taxation are opposed. The extension of this to medicine is that Libertarians favor private health insurance, where the healthy do not subsidize the unhealthy.

 Rawlsians, named after John Rawls of Harvard University, proposed that all social contracts should have morale restraints imposed, the most significant he called the "veil of ignorance". This means that social contracts should be made without regard to age, gender, race, health, number of dependents, income, wealth, or other arbitrary personal information. This justified his difference principle, whereas choosers should opt for institutions that create equality, unless a difference favors the least well-off group. The extension of this to medicine is every citizen should have equal access to medical care, unless unequal access favored the poor, which is a very unlikely prospect. This would equate to a state or federal, single-payer, system for all.

 Kantian ethics
Immanuel Kant (1724-1804), raised with strongly oriented, conservative, religious ethics, reverted during his university days to abstract reason, rather than metaphysical beliefs. He believed in the power of humans to use reason to solve their problems. The distinctive elements of Kantian ethics include:

 Ethics is not a matter of consequence but of duty. Why an act is done is more important than its good or bad results. Specifically, an act must be done from the right motive, and that is defined as the desire to do one's moral duty.

 A right act has a maxim that can be universalized. An action is right if one can will its "maxim" or rule to be acted on by all others. Hence, a lie cannot be right, because promise-keeping would be worth nothing.

 A right act always treats other humans as ends-in-themselves, never as a mere means. The welfare of one cannot be sacrificed for the good of others, or the desires of another. This means to treat another person as having absolute, infinite more worth, not relative worth. A physician must always tell the patient the truth.

 People are only free when they act rationally. Kant denies that we are truly acting morally when we do the right thing, because we are accustomed to it, because it feels right, or because society favors the act. The only time a person can act morally is when one exercises the rational, free will, to understand why certain rules are right and then chooses to bind oneself to those rules. Kant calls the capacity to act this way autonomy. For example, Kant's maxim applied to a utilitarian lifeboat commander, where all those in control of lifeboats should maximize survivors, even if it means denying access to some in the water.

Utilitarianism

The essential idea is that right acts should produce the greatest amount of good for the greatest number of people, called "utility". Utilitarianism does not urge people to turn the other cheek and hope for justice in another life, nor does it exalt those virtues so cherished by organized religions and society, particularly stylish dress, manners, personal honor, literacy, scientific and artistic accomplishment, and patriotism. They were also against slavery in the early 1800s. They attacked the penal system, ended debtor's prison, opposed capital punishment for petty thefts, and advocated the vote for women. They urged public hospitals, especially for the poor, the penny post system to make sending mail accessible to all, clean water, and sanitary waste disposal, including sewer systems. Utilitarianism's essence can be summed up in four basic tenets:

 Consequentialism: Consequences count, not motives or intentions.

 Maximization principle: The number of people affected by the consequences matter. The more people, the more important the effect.

 Theory of value or of "good": Good consequences are defined by pleasure (hedonic utilitarianism) or what people prefer (preference utilitarianism)

 Scope-of-morality premise: Each being's happiness is to count as one and no more.

For Utilitarians, right acts produce the greatest amount of good consequences for the greatest number of beings. Yes, animals are included in the greatest number. In medicine, there is a difference whether a provider listens, because they really care about patients, or because they have found that satisfied patients are an effective way to maximize income. A Utilitarian might argue that if the medical techniques are good enough to cause satisfaction, whether the provider really cares matters very little. The behavior produces good consequences to real people. The Utilitarian maxim inversely applied would be a dichotomy to medical ethics, permitting the sacrifice of one healthy person, so organs can be donated to four people who need them to live. More are healthier, when the one is sacrificed, ergo, a Utilitarian maxim gone astray.

 Principles and ethics
One modern method of analysis is to analyze a dilemma, or case of medical ethics, in terms of four basic principles distilled from the above ethical theories. Deciding what is the right thing to do in a particular case involves applying and balancing all four principles.

 Autonomy: Make personal decisions without coercion by others. John Stuart Mill was a political theorist, as well as an ethical theorist, and in his work, On Liberty (1859), defended "one very simple principle", his so-called harm principle. It states "the only purpose for which power can rightfully be exercised over any member of civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant...over himself, over his own body and mind, the individual is sovereign." Since the beginning of modern medical ethics (bio-ethics) in the early 1960s in America, autonomy has meant the patient's right to make his/her own decisions about her/his body, including dying and reproduction. It was not until the 1980s that the bio-ethicists admitted that the supreme value of autonomy must be assessed in light of other values, and weigh the sum in dictating answers in specific cases.

 Beneficence: Doing good to others. This is clearly tied to the Judeo-Christian-Muslim virtue of compassion and helping others. This virtue came to the fore in efforts to distinguish therapeutic from non-therapeutic experiments in patients. It is also a principle, since physicians receive special powers, income, and prestige from society. They require self-sacrifice, in training and in duty. Beneficence may come into conflict with autonomy, as well as any principle may conflict with another in a specific case, hence the "evaluative premise" concept. Consider the homeless schizophrenic and involuntary commitment. Is it better to let the person wander in the cold or incarcerate the person for medication and his own safety. Should we let them "die with their rights on?"

 Non-maleficence: Not harming others. This stems from the ancient medical ethics, "First, do no harm." Dr. Bill Kay made this quote popular in veterinary medicine at the Animal Medical Center in New York City, with his counsel to all new residents. It speaks to technical competency. Patients are in a teaching hospital to be helped, not for students to learn. This crucial bio-ethical principle prohibits corruption, incompetence, or dangerous non-therapeutic experiments. This principle supports both Mills "harm principle" and contractarianism. These minimalist moralities imply the state and society should not attempt to shape all citizens' lives for the goals of one world view, or unsolicited intrusions, just to help.

 Justice: Treating similar kinds of people similarly. This has both a social and a political interpretation. A physician is bound to treat each patient in a similar manner, regardless of insurance coverage. Of all the four principles, justice is the one that must be mediated by the other three in any bio-ethical decision. This is also one of the most abused bio-ethical virtues in veterinary medicine, especially when veterinary care givers make patient care decisions, for the client and without the client's informed consent, based on an arbitrary assumption of the client's ability to pay for the healthcare delivery. For example, the "recommend" in veterinary literature versus telling a client what is needed for the patient's welfare. Justice requires a high standard of behavior for every healthcare provider. Patients must be treated impartially, without bias on account of species, community, or wealth.

 Feminist ethics
In the early 1970s, a modern version of feminism shook American medicine to its foundations and buttressed its sister movement, the patient's rights initiatives. Both movements attempted to take patients' decisions about their bodies and lives away from the male-dominated physicians, and give women patients control. The landmark book was, Our Bodies, Ourselves, written by a group of women patients from Boston, who accessed one of the most grand, self-satisfied, medical centers in the world, Harvard. During the 1980s, feminist philosophers questioned whether many ways of knowing were the ways or merely male ways.

 Contractarianism, Kantianism, and Utilitarianism all looked like male-dominated theories, too abstract, too intellectual, and largely false to the ordinary experiences of many women. Where were the concepts on feminine values, such as cooperation, nurturing, and bonding?

 Carol Gilligan, Harvard University education professor, showed that many women analyzed ethical dilemmas differently from men. Subsequently, theorists articulated theories of ethics, whose central concepts were not rights or universalization, but caring, trust, and relationships.

 This started the "ethics of care", a branch of the virtue ethics tree, promoting caring, nurturing, trust, intimate friendship, and love. These are traits that most theorists considered "not natural" as virtues, but rather exist because they are encouraged in most women by traditional, sexist, gender roles.

 Ethics of care was a corrective action to the previous emphasis in ethical theory on abstract, semi-legalistic concepts. These old theories are still common in veterinary medicine today. Ethics of care reflected the modern society's turning inward to the family and to those around you, fighting battles close at hand, and letting far-off concerns, such as world hunger, take care of themselves.

 Many traditionalists labeled ethics of care a more modest, minimalist, approach to morality -- a kind of "within-my-circle-of-relationships" approach -- in which moral concerns usually arise among those one knows.

 From the new perspective, ethics of care is seen as an antidote to moral views that are cast only in terms of rights, utility, and duty.

 Ethics of care cannot yet be considered a complete ethical theory, for it does not tell us how to treat people we do not know or care about. This shortfall is the basis of the medical dilemma, for the healthcare provider must often treat strangers.

 This theory evolves day by day, and in decades to come will enter veterinary medicine.

 Case-based reasoning
Admittedly, many healthcare providers do not find any of the theories described above very useful to their practice of medicine. To force the complexities of the concurrent medical and pathophysiological systems of the living entity into a preconceived, abstract, framework of theoretical virtues and principles, is often oversimplification. When that happens, the truth is rarely discovered. Case-based reasoning reflects on known patients, in known conditions, such as the Karen Quinlan or Nancy Cruzan cases, where young women were left in "persistent vegetative states", contrary to the wishes of the parents. In retrospect, the answers appear clear, but when in the fray of healthcare delivery, decisions were clouded at best.

 Advocates of case-based reasoning believe these two cases alone lay a solid ground work for case-based reasoning.

 Medical paradigms should be formed from bedrock cases, from which we can generalize ever-expanding circles of similarity.

 By understand the arguments on both sides -- killing or letting one die, ordinary versus extraordinary, treatment versus withdrawal of treatment, standards of brain death, and models of proxy consent for making decisions about incompetent patients -- we hope to increase our understanding of related bio-ethical issues.

 Case-based reasoning does not deny that ethical theories and moral reasoning play important roles in moral life. When relevant to a case, they must be discussed. The argument is, therefore, at the "evaluative premise" phase, in deciding what elements are relevant, rather than the consequence or conclusion phase.

 Case-based reasoning is very similar to case-analysis used by the business schools today, and is the tradition of teaching on rounds in teaching hospitals. It is often called "casuistry" in theological reasoning.

 Each case or situation will present itself with a unique array of people. This will include interests, conflicting principles, incompatible role-duties, strong passions, and concerns about the larger good, about resources, about institutional policies, and about political consequences, including personal and institutional liability.

 Each set of circumstances will require what the Greeks called phronesis, or practical judgment, to find the optimal solution for all parties involved.