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By Dennis Mashindi
The utilization of ethics over the course of history has been implemented in general and specialized human activity to allow morals to guide society. From government to education, ethics has allowed communities to follow an objective and ever evolving moral code. This moral code is reflected through laws, policy, curriculum and standard operations. More specifically, within the medical realm, ethics has guided the relationship between patient and healer as early as the genesis of medicine and medicinal practices. Hippocrates, the father of modern medicine, is quoted with saying,” As to diseases, make a habit of two things — to help, or at least, to do no harm.” As we humans look to further advances in many avenues, the idea of ethics beckons what decisions we can and cannot make. When understanding the field of medicine, more specifically physicians, it is important to understand the relationship between ethics and its relationship to contemporary life. As the world advances, the world of medicine in the same has had to evolve with it. Ethics, Law and the Social Climate of the country all contribute equally to the success of the medical sector, and more importantly the nation’s physicians.
Ethics is officially defined as ,”moral principles that govern a person's behavior or the conducting of an activity. (Webster)” The point of ethics is to allow communities to utilize a common set of value and principles to guide decisions from activity to activity. Within the medical community, this word holds a lot of weight seeing that medicine and ethics are partners in many cases. From the early origins of medicine to its structure and infrastructure now, it is significant to see the role ethics and law play in the dynamics of our current medical system.
When analyzing the current atmosphere of current American Medicine, it is important to understand the origins of the medical structure. According to “200 Years of American Medicine” by the National Library of Medicine, the origins of the American Medical structure is best depicted during the war for independence in the 18th century. The signature of four physicians sit on the Declaration of Independence. Point to be made, the origins of medicine and the founding’s of this nation were built hand in hand. The issues that plagued our country’s origin too, became weeds in the field that would become what we see as our modern day medical infrastructure. As the country came out of the slavery era, black were not afforded the same health pursuits as their white counter parts. Harvard’s own Nancy Krieger, professor of social epidemiology shared research findings documenting higher black infant mortality rates in Jim Crow states prior to the passage of the 1964 Civil Rights Act. With that, many hospitals in the South didn’t allow blacks to be treated or would allow accommodation in the basement of facilities. In North, black physicians weren’t given the same benefits as white physicians & black patients were often sent to “black institutions” or county hospitals. As the social scene has radically change, the medical atmosphere too had to change. With that said however, the same social issues stemming from the origins and sins of this country have found ways to manifest themselves through many different avenues in our current medical infrastructure. From racism, to sexism to the failure to accommodate different groups from across the background spectrum, our medical system had its ups and downs.
The American Medical Association lays out the code of ethics to be used and abided by all physicians practicing medicine within the United States’ borders. Founded in 1847, the American Medical Association established the world’s first national code for ethical medical practice, the AMA Code of Medical Ethics. Within the Principles of Medical Ethics (first chapter of the Medical Code of Ethics) , verse three states the following .”III. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.” As the United States has seen both sunshine and clouds in respect to its complicated history, the ever changing of laws and rules by legislation is a topic that is always of conversation. From the 13th amendment to 19th amendment, the country within the last 155 years had seen a lot of progress on the legislation side. But to now put things in perspective, this same ethical code one hundred and sixty years ago would see the treatment of patients in a different light. In accordance to American Law, black persons within the confines of slavery were not considered people, but property. This meant that their lives and decisions were not of their own possession legally but of their master. Away from slavery, many ethical injustices were carried out at the hand of physicians and scientists looking to further scientific advances. In 1932, Doctors from the US Public Health Service infected over 350 black men in the Tuskegee Area with syphilis to understand the innerworkings of the disease. Instead of trying to give treatments to said participants, it was decided that patients wouldn’t be given effective care as many died, become blind or experienced other dire health issues. From this, 120 participants died, with 59 other people infected being spouses and children. Sadly, this experiments happened at the collaboration of both the law and the medical field. In relation to the current ethical codes provided by the American Medical Association, the codes relay that physicians shall support the access to medical care for all people. However, the laws of the 18th, 19th ,and 20th century didn’t see colored people as people at all, but as mere property and projects. In summation, the ethical codes of a physician only can be uplifted in an environment where both the law and medicine work for true ethical purposes.
As ethics continue to guide physicians in the proper ways to engage with the general public, it is important to also examine the relationship between the law and ethics in the contemporary context. As election comes close to full swing, the topic of women’s rights has become again a popular topic of conversation. In the past Democratic Debate, candidates were asked if and in what ways they intended to protect abortion. The issue of abortion is one that originally stems from the Supreme Court cases, Roe v. Wade & Doe v. Bolton, where abortion was decriminalized nationwide. The topic of abortion within political circles is one that is very polarized. There are two sides to the issue, dubbed “ Pro-Life” and “Pro-Choice”. Planned Parenthood defines Pro-Choice as,” Generally, people who identify as pro-choice believe that everyone has the basic human right to decide when and whether to have children. When you say you’re pro-choice you’re telling people that you believe it’s OK for them to have the ability to choose abortion as an option for an unplanned pregnancy — even if you wouldn’t choose abortion for yourself.” Pro-Life is defined by ThoughtCo as “the government has an obligation to preserve all human life, regardless of intent, viability, or quality-of-life concerns”. The two sides have created a very polarized scene in regards to what a woman should and shouldn’t do in regards to reproductive rights. According to the Guttmacher Institute,”43 states prohibit abortions, generally except when necessary to protect the woman’s life or health, after a specified point in pregnancy.” To understand the holistic scope of abortion, it is important to see how the law has the final say as to what people can and cannot do. Regardless of the side seen on this debate, it is important to also see the intersectionality between physician, the law and ethics. Many see that the issue of women’s rights should be left for women to decide seeing that the rights will affect women. Others use religion and other beliefs to justify the opposition to this argument. Beliefs aside, the law dictates how the states and the country should be governed. For a physician who believes the pro-choice side of the argument as their ethical belief, carrying out an abortion aside from the exceptions stated by law and by ethical code can mean punishment due to the required adherences by physicians to the law. Ethics gives all physicians a foundation value premise to follow, however, that ethical code may not be the values held by a certain physician.
In the book, “New Public Health Law” , the dissonance between legal doctrine and the health of the public is highlighted in the first chapter. The book cites a word being “Negative Constitution”. These coined terms refer to the fact that the constitution allows but does not mandate the government to protect or even provide health services for the general public. This is very evident in the fact that our healthcare system is one not built to provide healthcare for every citizen but rather give every citizen the ability to buy healthcare for themselves and others. In relation to the ethical code of physicians in the United States, it seems counter intuitive that the ethical code would require physicians observe the law, even if the laws don’t protect the provision, treatment and wellbeing of the patient.
Moving the through the Code of Medical Ethics, it is laid out how a physician should treat the community around them as they continue to work and serve their patients. “a) Provide care that meets patient needs and respects patient preferences. (b) Avoid stereotyping patients” As 2019 came to a close, it was disheartening to see numerous stories in reference to black women and pregnancy. Black women, statistically speaking, are more at risk of dying from pregnancy complications than any other demographic here in the United States. According to the American Heart Association, the maternal mortality rate in the United States is the worst in any industrialized country. The AHA goes on to quote Dr. Ana Langer, the director of the Women and Health Initiative at the Harvard T.H Chan School of Public Health in Boston. Langer says,” "Basically, black women are undervalued. They are not monitored as carefully as white women are. When they do present with symptoms, they are often dismissed." Though the Code of Ethics say that doctors should “avoid stereotyping patients” , the reality is that we as a country are failing certain demographics and violating this code every time a black woman dies in the hand of irresponsible healthcare personnel. Dr. Allison Bryant Mantha, vice chair of quality, equity and safety in the obstetrics and gynecology department of Massachusetts General Hospital in Boston says this in the same article, “ "Both implicit bias and structural racism affect how women are cared for in the health care system." The words implicit bias is used to often describe the lack of care given to black women in the medical space. According to the Kirwan Institute, “the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner.” Doctors are failing to look at black women as mere patients and people but as stereotypes whose issues are as important or significant as other demographics. In a research paper written by Dr. Mary Berth Flanders- Stephan, black women have had the higher mortality rate than any other female demographic since 1999. Black women are two to six times more likely to die from pregnancy complications depending on their location of birth. The leading causes of deaths are hemorrhages, pregnancy induced hypertensions, and embolisms. The Medical Code of Ethics tells physicians to be cautious in the way that they treat their patients but the reality is, there are more factors that are going on behind the scenes.
As stated previously, the erection of medical infrastructure of the United States is hand in hand with the founding of America. The issues that plague America now and its past have manifested themselves in the American Health System. Along with legal constraints, as some legal avenues don’t protect the all citizens, the social atmosphere of our country still struggles to keep up with a progressive public. The social progress of the country has, however reflected itself within the Code of Ethics used by physicians. The Code of Ethics deliberates the correct treatment of those with HIV, the treatment of different demographics and the correct ways to approach different community values and beliefs. However, the code has a long way to go with this most recent new headline.
The titles reads,” ICE is…in Violation of Medical Ethics (VICE News)” To further understand the issue at hand, it is important to understand the context behind this headline and many more like it. In the election of 2016, then Presidential candidate Donald Trump was very known for his slogan, “ Build that Wall”. His sentiment towards “illegal immigrants” were that they should go back to their homes regardless of the circumstances that brought them to the United States to begin with. As Trump saw a victory in that election, he was keen on making sure that his agenda was to be pushed. In 2019, the United State saw very harsh and aggressive measures taken on by the Immigrations and Customs Enforcement to carry out the Trump agenda. Media photos depicted raids, family separations and the imprisonment of children and adults alike in cages. Once again, regardless of opinion on the matter, many public health issues occurred in the facilities where people were being held. Vice News reported on the death of a toddler who became sick at an ICE detention center and later passed away. Other reports covered the inhuman treating of immigrants being held in detention centers across the southern border. Children were put in cages and given what could be seen as aluminum foil blankets. According to TIME Publications, Adults and children were held for prolonged period of time without access to soap, toothpaste, or water to clean themselves. ”Some reports have emerged of children sleeping on concrete floors; others of adults having to stand for days due to lack of space” From these conditions, 24 immigrants including seven children have died at the hands of the US government. In relation to ethics and the line of occupation for physicians, this calls into to question to the ethics of our governmental structure and the duty of physicians to patients, with or without citizenship. Katharina Obser, senior policy adviser at the Women's Refugee Commission, an advocacy group. "The U.S. government is not even doing the bare minimum to ensure [immigrants] are getting the medical care and the mental health care they need." The ethical code used by physicians calls for dependence , once again, on the law of the land. This issue shows that the current system was and is ill equipped to have laid into effect actions to detain those without citizenship in facilities not prepared to care for their basic human rights. Physicians can only carry out their duty effectively and ethically if the law and the government behind them is setting both effective and ethical laws to be followed and enforced. The American Civil Liberties Union and the National Immigrant Justice Center found that violations of medical care standards played a big part in custody deaths from earlier years. The role of the law and ethics from the medical perspective should be to provide ample healthcare for all and protect vulnerable populations. Though the shortcomings from the ICE detention centers don’t fall wholly on the medical community, the failure for the law and the medical community to work cohesively to provide ethical solutions to our country’s ever evolving social and political scene resulted in the deaths of people looking to be a part of what the world sees as a land of opportunity. Though the system has seen a lot of valleys, there is hope for our medical sector to live up to the ethical expectations we hope to see.
In 2010, Barack Obama introduced the first effort to see health insurance expanded to groups in the country who had struggled to have health insurance. The Affordable Care Act is comprehensive healthcare reform that extended Medicaid eligibility, prevented health insurance companies from denying coverage due to pre-existing conditions, gave low-income earning families the opportunity to qualify for savings on health insurance via premium tax credits and cost sharing reductions (Investopedia). Though the reform bill wasn’t one-hundred percent perfect, it introduced to the American public health care as a commodity that should be accessible for everyone. Health insurance is needed for medical care to be given in this country. The lack of health insurance can result in failure to be treated or a grandiose cost bill that is eventually assumed by the public. Doctors nationwide understand the need for a system to be in place to allow the general public the access to have health insurance. According to Forbes, “ A majority of U.S. physicians see the ACA as a “net positive” for the U.S. healthcare system.” With the support of the American Academy of Family Physicians, the American College of Physicians ,and the American Medical Association (the authors of the Code of Ethics for all physicians), doctors nationwide are making a statement as they “have opposed efforts by the Trump administration and Republicans in Congress to derail the ACA.” In Chapter 11.2.1 Professionalism in Health Care System, verse (f) states “Recognize physicians’ primary obligation to their patients by enabling physicians to respond to the unique needs of individual patients and providing avenues for meaningful appeal and advocacy on behalf of patients. “We as a country are starting to recognize that the grooming of a healthy population only is to our benefit. Physicians nationwide are contributing to conversations that will see the advocacy of current and to be patients by seeing that health is accessible to all. It is through this demonstration, that ethicality and purpose can be restored to the American health system.
Medical pursuit is nothing without the implementation of ethics. Ethics gives us as humans a way to interact and to engage with each other and our environments in a way to where we understand and can see our humanity. Though we are not perfect as a society, it takes actors to recognize our issues, and to dedicate their work and efforts to seeing these problems solved. We as a nation and as a people have had to deal with the sins of our past and present. The failure to look these problem in the face and pursue a better tomorrow plays to the detriment of the community and the future. Ethics, law and the social environment must work in cohesivity for there to be true progress in the medical sector. It is evident when these factors are in opposition, room for human experimentation, exploitation and abuse become the avenues to which we as a societal people operate in our medical pursuits. Though we are not perfect, there is hope in a system that provided healthcare for all, protects the vulnerable and sees the uplifting of communities across the board.
Works Cited
Dolven, Taylor, and Kathleen Caulderwood. “This Toddler Got Sick in ICE Detention. Two Months Later She Was Dead.” VICE News, VICE News, 27 Aug. 2018, news.vice.com/en_us/article/paw9ky/toddler-died-after-getting-sick-in-ice-custody.
“Harvard T.H. Chan School of Public Health.” Nancy Krieger, www.hsph.harvard.edu/nancy-krieger/.
Japsen, Bruce. “Doctor Obamacare Support Grows.” Forbes, Forbes Magazine, 4 Sept. 2019, www.forbes.com/sites/brucejapsen/2019/09/03/doctor-obamacare-support-grows/#4a16de426b32.
“The Opinions in This Chapter Are Offered as Ethics ...” AMA: Code of Ethics , American Medical Association , www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/code-of-medical-ethics-chapter-11.pdf.
“The New Public Health Law.” Scott Burris; Micah L. Berman; Matthew Penn; Tara Ramanathan Holiday - Oxford University Press, 7 Feb. 2020, global.oup.com/academic/product/the-new-public-health-law-9780190681050?cc=us&lang=en&.
“Abortion.” American Medical Association, www.ama-assn.org/delivering-care/ethics/abortion.
Dennis Mashindi is a McConnell Scholar in the Class of 2021. He is studying public health, political science, and biology at the University of Louisville.